Provider Demographics
NPI:1952557019
Name:TUCKER, JAMI GLYNN
Entity Type:Individual
Prefix:
First Name:JAMI
Middle Name:GLYNN
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 1:5590 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-9694
Mailing Address - Country:US
Mailing Address - Phone:336-922-0456
Mailing Address - Fax:
Practice Address - Street 1:523 LYNCHBURG RD
Practice Address - Street 2:
Practice Address - City:PILOT MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:27041-9326
Practice Address - Country:US
Practice Address - Phone:336-408-0821
Practice Address - Fax:336-232-1411
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4662225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics