Provider Demographics
NPI:1205184280
Name:TUCKER, JESSICA ANN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:LUEVANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10215 LAKE CITY WAY NE STE H
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-7758
Mailing Address - Country:US
Mailing Address - Phone:206-417-9904
Mailing Address - Fax:
Practice Address - Street 1:10215 LAKE CITY WAY NE STE H
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-7758
Practice Address - Country:US
Practice Address - Phone:206-417-9904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA637751041C0700X
171M00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program