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General NPI Number Information
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NPI Number | 1225527351
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Entity Type | Organization
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Legal Business Name | TIDEWATER MOBILE MEDICINE, PLLC
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Dates
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Enumeration Date | 05/03/2018
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Last Update Date | 01/21/2022
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Provider Practice Location Address
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Address Line | 3520 HIGH ST STE 100
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City | PORTSMOUTH
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State | VA
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Zip | 23707-3126
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Country | US
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Telephone | 757-977-9675
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Fax | 757-483-8099
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Provider Business Mailing Address
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Address Line | 3520 HIGH ST STE 100
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City | PORTSMOUTH
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State | VA
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Zip | 23707-3126
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Country | US
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Telephone | 757-977-9675
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Fax | 757-483-4099
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Authorized Official
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Title or Position | CEO/OWNER
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Name | DR. JIMMY COOPER JR.
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Credential | DHA, FNP-C
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Telephone | 757-977-9675
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 46193
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License Number State | VA
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Taxonomy #4
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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