Provider Demographics
NPI:1407998404
Name:TUCKER, JERRY DEWAYNE
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DEWAYNE
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:US COAST GUARD SPECIAL MISSIONS TRAINING CENTER
Mailing Address - Street 2:BB-11 COURTHOUSE BAY
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542
Mailing Address - Country:US
Mailing Address - Phone:910-376-0773
Mailing Address - Fax:910-450-7040
Practice Address - Street 1:US COAST GUARD SPECIAL MISSIONS TRAINING CENTER
Practice Address - Street 2:BB-11 COURTHOUSE BAY
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-376-0773
Practice Address - Fax:910-450-7040
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist