Provider Demographics
NPI:1336497163
Name:TUCKER, JON
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:H.C. 69 BOX 300
Mailing Address - Street 2:
Mailing Address - City:FINLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74543
Mailing Address - Country:US
Mailing Address - Phone:580-271-0087
Mailing Address - Fax:
Practice Address - Street 1:HC 69 BOX 300
Practice Address - Street 2:
Practice Address - City:FINLEY
Practice Address - State:OK
Practice Address - Zip Code:74543-9641
Practice Address - Country:US
Practice Address - Phone:580-271-0087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid