Provider Demographics
NPI:1073007324
Name:TUCKER, KAPREISHA D
Entity type:Individual
Prefix:
First Name:KAPREISHA
Middle Name:D
Last Name:TUCKER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 KETTNER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2421
Mailing Address - Country:US
Mailing Address - Phone:619-865-0561
Mailing Address - Fax:
Practice Address - Street 1:1420 KETTNER BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2421
Practice Address - Country:US
Practice Address - Phone:619-865-0561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2025-03-20
Deactivation Date:2020-03-03
Deactivation Code:
Reactivation Date:2020-03-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty