Provider Demographics
NPI:1841295359
Name:JUCKETT, ALICIA JACKSON (LPT)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:JACKSON
Last Name:JUCKETT
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 CORDOVA ROAD
Mailing Address - Street 2:STE 107
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-0517
Mailing Address - Country:US
Mailing Address - Phone:901-756-1650
Mailing Address - Fax:901-756-1396
Practice Address - Street 1:8110 CORDOVA RD
Practice Address - Street 2:STE 107
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-0520
Practice Address - Country:US
Practice Address - Phone:901-756-1650
Practice Address - Fax:901-756-1396
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3658738Medicare ID - Type Unspecified