Provider Demographics
NPI:1417470337
Name:TUCKER, JONATHAN (LAT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7083 BRIAR RD
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-7033
Mailing Address - Country:US
Mailing Address - Phone:817-253-5820
Mailing Address - Fax:
Practice Address - Street 1:1801 S STEWART ST
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3068
Practice Address - Country:US
Practice Address - Phone:817-253-5820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT56262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer