Organization
TIDEWATER MOBILE MEDICINE, PLLC
Active
Parent organization
TIDEWATER MOBILE MEDICINE PLLC
Other names
Authentic Self Counseling Services, TMM Medical Group
Organization subpart
Yes
Provider details
NPI number
Legal business name
TIDEWATER MOBILE MEDICINE PLLC
Authorized official
DR. JIMMY COOPER JR. DHA, FNP-C (CEO/OWNER)
(757) 977-9675
Entity
Organization
Contact information
Practice address
3520 HIGH ST STE 100, PORTSMOUTH, VA 23707-3126
(757) 977-9675
(757) 483-8099
Mailing address
3520 HIGH ST STE 100, PORTSMOUTH, VA 23707-3126
(757) 977-9675
(757) 483-4099
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
1041C0700X
Clinical Social Worker
—
—
207Q00000X
Family Medicine Physician
Primary
—
—
261QP2300X
Primary Care Clinic/Center
46193
VA
343900000X
Non-emergency Medical Transport (VAN)
—
—
Other
Enumeration date
05/03/2018
Last updated
01/21/2022
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