Provider Demographics
NPI:1194451468
Name:TIDMORE, JASELYN HARRISON (OTR/L)
Entity type:Individual
Prefix:
First Name:JASELYN
Middle Name:HARRISON
Last Name:TIDMORE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 HIGHWAY 61
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:AL
Mailing Address - Zip Code:35051-5258
Mailing Address - Country:US
Mailing Address - Phone:205-566-2798
Mailing Address - Fax:
Practice Address - Street 1:209 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:AL
Practice Address - Zip Code:35051-9724
Practice Address - Country:US
Practice Address - Phone:205-210-4980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5218225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5218OtherOCCUPATIONAL THERAPY LICENSE NUMBER