Basic Information
Provider Information | |||||||||
NPI: | 1134387558 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TIDWELL | ||||||||
FirstName: | JERITHEA | ||||||||
MiddleName: | DORONICE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN PHD, PNP, PCNS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1935 MEDICAL DISTRICT DR | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752357701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2144562331 | ||||||||
FaxNumber: | 2144562897 | ||||||||
Practice Location | |||||||||
Address1: | 1935 MEDICAL DISTRICT DR | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752357701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2144562331 | ||||||||
FaxNumber: | 2144562897 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2008 | ||||||||
LastUpdateDate: | 09/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | APN0000011923 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 364S00000X | AP117669 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |   | 364SP0200X | 659941 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Pediatrics | 364SP0200X | APN0000011923 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Pediatrics | 363LP0200X | AP117669 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.