Provider Demographics
NPI:1083662373
Name:JOHNSON, TUCKER D (PHD)
Entity Type:Individual
Prefix:DR
First Name:TUCKER
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 COVINGTON ST
Mailing Address - Street 2:PO BOX 147
Mailing Address - City:STANTON
Mailing Address - State:TN
Mailing Address - Zip Code:38069-4428
Mailing Address - Country:US
Mailing Address - Phone:731-548-6562
Mailing Address - Fax:731-548-6563
Practice Address - Street 1:2014 EXETER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3945
Practice Address - Country:US
Practice Address - Phone:901-624-4600
Practice Address - Fax:901-757-1485
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000002427103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00329380OtherMEDICARE RAILROAD
3642980Medicare PIN