Provider Demographics
NPI:1255932539
Name:RUCKS, JORDAN TAYLOR
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAYLOR
Last Name:RUCKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HOLLINGSWORTH PL
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-2111
Mailing Address - Country:US
Mailing Address - Phone:772-214-5356
Mailing Address - Fax:
Practice Address - Street 1:17 HOLLINGSWORTH PL
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-2111
Practice Address - Country:US
Practice Address - Phone:772-214-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program