Provider Demographics
NPI:1700937638
Name:TUCKER, JAMES L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:L
Last Name:TUCKER
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 1:124 E MIRACLE STRIP PKWY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1988
Mailing Address - Country:US
Mailing Address - Phone:850-243-8086
Mailing Address - Fax:850-243-2702
Practice Address - Street 1:124 E MIRACLE STRIP PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1988
Practice Address - Country:US
Practice Address - Phone:850-243-8086
Practice Address - Fax:850-243-2702
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO732103TC0700X, 103TC2200X
FLPY9444103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3215OtherMEDICARE GROUP
FLIL179ZMedicare PIN