MEDICARE: DR. JESSICA J TIDSWELL PT, DPT, SCS, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5080663-2401	UT

General Provider Information

NPI Number	:	1952593568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA J TIDSWELL PT, DPT, SCS, ATC

Provider Business Mailing Address
First Line	:	515 ASPEN DR
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5134
Country	:	US
Telephone Number	:	801-718-5378
Fax Number	:

Provider Business Practice Location Address
First Line	:	2760 RASMUSSEN RD
Second Line	:	SUITE D2-D3
City	:	PARK CITY
State	:	UT
Zip	:	84098-5684
Country	:	US
Telephone Number	:	801-718-5378
Fax Number	:	801-718-5378

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2007
Last Update Date	:	12/27/2021

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