Provider Demographics
NPI:1740283001
Name:TUCKER, JESSICA (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 S PEAK DR STE 101
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-9693
Mailing Address - Country:US
Mailing Address - Phone:910-908-4673
Mailing Address - Fax:910-905-2242
Practice Address - Street 1:3351 S PEAK DR STE 101
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-9693
Practice Address - Country:US
Practice Address - Phone:910-908-4673
Practice Address - Fax:910-908-2242
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89131KKMedicaid
NC89131KKMedicaid
NC2010278BMedicare ID - Type UnspecifiedPROVIDER NUMBER