Provider Demographics
NPI:1164868709
Name:TUCKER, JUSTINE (LAC, MHP)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LAC, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4171 N CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4591
Mailing Address - Country:US
Mailing Address - Phone:479-521-1427
Mailing Address - Fax:479-521-6520
Practice Address - Street 1:2003 SE WALTON BLVD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3725
Practice Address - Country:US
Practice Address - Phone:479-464-5925
Practice Address - Fax:479-464-4275
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ARA1601002101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator