Provider Demographics
NPI:1235405721
Name:RUCKER, TRACY JONES (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:JONES
Last Name:RUCKER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 S WOOD DUCK DR
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:24572-4647
Mailing Address - Country:US
Mailing Address - Phone:434-929-0815
Mailing Address - Fax:
Practice Address - Street 1:1900 THOMSON DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1009
Practice Address - Country:US
Practice Address - Phone:434-947-2888
Practice Address - Fax:434-947-2389
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003610235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist