Provider Demographics
NPI:1336131994
Name:TUCKER, KIMBERLY JAN (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JAN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 GROOMSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-2673
Mailing Address - Country:US
Mailing Address - Phone:770-880-7684
Mailing Address - Fax:
Practice Address - Street 1:10100 GROOMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-2673
Practice Address - Country:US
Practice Address - Phone:770-880-7684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET001021235Z00000X
GASLP00006300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA637018452AMedicaid
GA10033374Medicaid
GA52703821 002OtherBLUE CROSS & BLUE SHIELD