Provider Demographics
NPI:1982725230
Name:TUCKER, JEFFREY ALAN (MSPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SE GOLDTREE DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7582
Mailing Address - Country:US
Mailing Address - Phone:772-335-7966
Mailing Address - Fax:772-335-7963
Practice Address - Street 1:1400 SE GOLDTREE DR
Practice Address - Street 2:SUITE 205
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7582
Practice Address - Country:US
Practice Address - Phone:772-335-7966
Practice Address - Fax:772-335-7963
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 12440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650023083OtherRAILROAD MEDICARE PROVIDER NUMBER
FL650023083OtherRAILROAD MEDICARE PROVIDER NUMBER