Provider Demographics
NPI:1821080292
Name:RUCKER, JOHN P (PHD EDD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:RUCKER
Suffix:
Gender:M
Credentials:PHD EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6885 CLIFFDALE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2833
Mailing Address - Country:US
Mailing Address - Phone:910-339-0400
Mailing Address - Fax:910-339-0396
Practice Address - Street 1:6885 CLIFFDALE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2833
Practice Address - Country:US
Practice Address - Phone:910-339-0400
Practice Address - Fax:910-339-0396
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1230103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0384WOtherBSBCNC
NC6000078Medicaid
NC680011983OtherRR MEDICARE
NC6000078Medicaid