Provider Demographics
NPI:1336204833
Name:TUCKER, JACQUELYN NMI (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:NMI
Last Name:TUCKER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 E PERSHING ST
Mailing Address - Street 2:
Mailing Address - City:EASTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:76448-3547
Mailing Address - Country:US
Mailing Address - Phone:254-629-1956
Mailing Address - Fax:254-629-2851
Practice Address - Street 1:500 W PLUMMER ST
Practice Address - Street 2:
Practice Address - City:EASTLAND
Practice Address - State:TX
Practice Address - Zip Code:76448-2629
Practice Address - Country:US
Practice Address - Phone:254-629-3393
Practice Address - Fax:254-629-2851
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX229661363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B7772Medicare PIN
TXS22331Medicare UPIN