Provider Demographics
NPI:1285639401
Name:TUCKER, JAMIE (PA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38503-0938
Mailing Address - Country:US
Mailing Address - Phone:866-313-5259
Mailing Address - Fax:205-313-5298
Practice Address - Street 1:142 W 5TH ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-1760
Practice Address - Country:US
Practice Address - Phone:866-313-5259
Practice Address - Fax:205-313-5298
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3666888Medicare ID - Type UnspecifiedVMG MEDICARE
S39040Medicare UPIN