Provider Demographics
NPI:1689068264
Name:TUCKER, JERITT ROSS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERITT
Middle Name:ROSS
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S FLOWER ST STE 1000
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4112
Mailing Address - Country:US
Mailing Address - Phone:213-600-6096
Mailing Address - Fax:617-665-3449
Practice Address - Street 1:700 S FLOWER ST STE 1000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4112
Practice Address - Country:US
Practice Address - Phone:213-600-6096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-23
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083818103TC1900X
CA31412103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling