Provider Demographics
NPI:1952016388
Name:TUCKER, JASMINE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9067 DORAL CT APT C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-3354
Mailing Address - Country:US
Mailing Address - Phone:317-771-3006
Mailing Address - Fax:
Practice Address - Street 1:7098 N SHADELAND AVE STE F
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4275
Practice Address - Country:US
Practice Address - Phone:317-771-3006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-03-14
Deactivation Date:2023-01-19
Deactivation Code:
Reactivation Date:2023-03-13
Provider Licenses
StateLicense IDTaxonomies
IN171W00000X
171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor