Provider Demographics
NPI:1851482707
Name:LUCKETT, JEFFREY BLAKE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BLAKE
Last Name:LUCKETT
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 1:3635 MANASSAS DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-4031
Mailing Address - Country:US
Mailing Address - Phone:540-774-4686
Mailing Address - Fax:540-989-8893
Practice Address - Street 1:3635 MANASSAS DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4031
Practice Address - Country:US
Practice Address - Phone:540-774-4686
Practice Address - Fax:540-989-8893
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001414103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA046086OtherANTHEM
VA680000035Medicare ID - Type Unspecified