Provider Demographics
NPI:1770154478
Name:TUCKER, JASON EDWARD II (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:EDWARD
Last Name:TUCKER
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3900 CITY AVE APT M1119
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 SHURS LN STE 203
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19127-2123
Practice Address - Country:US
Practice Address - Phone:215-482-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT223663207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine