Provider Demographics
NPI:1184590028
Name:TUCKER, JANICE NINA
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:NINA
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 1:200 N PATRICK BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5883
Mailing Address - Country:US
Mailing Address - Phone:414-808-8108
Mailing Address - Fax:414-808-8108
Practice Address - Street 1:200 N PATRICK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5883
Practice Address - Country:US
Practice Address - Phone:414-808-8108
Practice Address - Fax:414-808-8108
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty