Provider Demographics
NPI:1952095556
Name:TUCKER, JERRY LAN (RDN)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LAN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 GOLF COURSE RD NW STE 183
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5842
Mailing Address - Country:US
Mailing Address - Phone:917-334-2823
Mailing Address - Fax:
Practice Address - Street 1:715 DR MARTIN LUTHER KING JR AVE NE STE 102
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3666
Practice Address - Country:US
Practice Address - Phone:505-727-3028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD2023084133VN1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology