Provider Demographics
NPI:1770728263
Name:TUCKER, JEAN C (MED,CCC-SLP)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:C
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 PORTSMOUTH AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:EXETER
Mailing Address - State:NH
Mailing Address - Zip Code:03833-2133
Mailing Address - Country:US
Mailing Address - Phone:603-583-4514
Mailing Address - Fax:603-583-4513
Practice Address - Street 1:92 PORTSMOUTH AVE
Practice Address - Street 2:STE 4
Practice Address - City:EXETER
Practice Address - State:NH
Practice Address - Zip Code:03833-2133
Practice Address - Country:US
Practice Address - Phone:603-583-4514
Practice Address - Fax:603-583-4513
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0782235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0782OtherLICENSED ALLIED HEALTH PROFESSIONALS
NH30401311Medicaid