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General NPI Number Information
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NPI Number | 1316270085
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Entity Type | Organization
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Legal Business Name | JADA TIDWELL, INC
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Dates
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Enumeration Date | 09/14/2009
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Last Update Date | 09/14/2009
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Provider Practice Location Address
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Address Line | 215 CHURCH ST STE 105
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City | DECATUR
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State | GA
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Zip | 30030-4617
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Country | US
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Telephone | 404-797-0889
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Fax | 404-378-2039
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Provider Business Mailing Address
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Address Line | 215 CHURCH ST STE 105
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City | DECATUR
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State | GA
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Zip | 30030-4617
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Country | US
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Telephone | 404-797-0889
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Fax | 404-378-2039
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Authorized Official
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Title or Position | OWNER
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Name | DR. JADA A. TIDWELL
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Credential | PH.D.
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Telephone | 404-797-0889
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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