Provider Demographics
NPI:1467950162
Name:JEAN, LUCKO
Entity Type:Individual
Prefix:
First Name:LUCKO
Middle Name:
Last Name:JEAN
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 1:205 GIBBS POND RD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2265
Mailing Address - Country:US
Mailing Address - Phone:631-432-9691
Mailing Address - Fax:631-257-5866
Practice Address - Street 1:205 GIBBS POND RD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2265
Practice Address - Country:US
Practice Address - Phone:631-432-9691
Practice Address - Fax:631-257-5866
Is Sole Proprietor?:No
Enumeration Date:2018-01-28
Last Update Date:2018-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04582707Medicaid