Provider Demographics
NPI:1497513857
Name:TUCKER, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
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 1:321 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:DURYEA
Mailing Address - State:PA
Mailing Address - Zip Code:18642-1001
Mailing Address - Country:US
Mailing Address - Phone:570-299-1525
Mailing Address - Fax:
Practice Address - Street 1:321 RIVER ST
Practice Address - Street 2:
Practice Address - City:DURYEA
Practice Address - State:PA
Practice Address - Zip Code:18642-1001
Practice Address - Country:US
Practice Address - Phone:570-299-1525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCSTUDENT111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor