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General NPI Number Information
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NPI Number | 1700443843
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Entity Type | Individual
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Provider Name | JENNIFER TISDALE
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Gender | Female
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Dates
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Enumeration Date | 05/23/2019
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Last Update Date | 12/26/2024
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Provider Practice Location Address
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Address Line | 136 US 70 HWY E
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City | GARNER
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State | NC
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Zip | 27529-3982
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Country | US
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Telephone | 919-791-5611
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Fax |
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Provider Business Mailing Address
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Address Line | 1107 MORDECAI DR APT 202
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City | RALEIGH
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State | NC
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Zip | 27604-1357
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Country | US
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Telephone | 919-413-7900
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C017933
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | PO13258
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License Number State | NC
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