Provider Demographics
NPI:1770582710
Name:TUCKER, JEFFREY A (D C)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:TUCKER
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:GENTRY
Mailing Address - State:AR
Mailing Address - Zip Code:72734-0936
Mailing Address - Country:US
Mailing Address - Phone:479-736-8900
Mailing Address - Fax:479-736-5133
Practice Address - Street 1:1179 S GENTRY BLVD
Practice Address - Street 2:
Practice Address - City:GENTRY
Practice Address - State:AR
Practice Address - Zip Code:72734-9624
Practice Address - Country:US
Practice Address - Phone:479-736-8900
Practice Address - Fax:479-736-5133
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1649111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158084718Medicaid
AR158084718Medicaid
AR5Y355Medicare ID - Type Unspecified