Individual
RYAN CHRISTIAN JENNINGS-TIDWELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1042 SE 30TH PL, TROUTDALE, OR 97060-9456
(503) 618-9668
Mailing address
23633 SE GOLD RD, EAGLE CREEK, OR 97022-9790
(503) 719-1518
Taxonomy
Speciality
Code
Description
License number
State
253Z00000X
In Home Supportive Care Agency
Primary
854291
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
854291
HCW PROVIDER NUMBER
OR
Enumeration date
08/14/2021
Last updated
08/14/2021
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