# TIDEWATER MOBILE MEDICINE, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** TIDEWATER MOBILE MEDICINE PLLC
- **Other names:** Authentic Self Counseling Services, TMM Medical Group
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1225527351
- **Legal business name:** TIDEWATER MOBILE MEDICINE PLLC
- **Authorized official:** DR. JIMMY COOPER JR. DHA, FNP-C (CEO/OWNER)
- **Authorized official phone:** (757) 977-9675

## Contact information

- **Practice address:** 3520 HIGH ST STE 100, PORTSMOUTH, VA 23707-3126
- **Practice address phone:** (757) 977-9675
- **Practice address fax:** (757) 483-8099
- **Mailing address:** 3520 HIGH ST STE 100, PORTSMOUTH, VA 23707-3126
- **Mailing address phone:** (757) 977-9675
- **Mailing address fax:** (757) 483-4099

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YA0400X | Addiction (Substance Use Disorder) Counselor | — | NULL | — |
| 101YA0400X | Addiction (Substance Use Disorder) Counselor | — | — | — |
| 1041C0700X | Clinical Social Worker | — | NULL | — |
| 1041C0700X | Clinical Social Worker | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 261QP2300X | Primary Care Clinic/Center | 46193 | VA | — |
| 343900000X | Non-emergency Medical Transport (VAN) | — | NULL | — |

## Other

- **Enumeration date:** 05/03/2018
- **Last updated:** 01/21/2022