Provider Demographics
NPI:1346459823
Name:ST. GEORGE TUCKER, JODY ANN (MT-BC, MA)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:ANN
Last Name:ST. GEORGE TUCKER
Suffix:
Gender:F
Credentials:MT-BC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2645 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55810
Mailing Address - Country:US
Mailing Address - Phone:218-349-1792
Mailing Address - Fax:
Practice Address - Street 1:2645 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55810-2112
Practice Address - Country:US
Practice Address - Phone:218-349-1792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN07105225A00000X
07105225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN07105OtherMUSIC THERAPIST