Provider Demographics
NPI:1124298161
Name:RUCKLE, JON LESLIE (MD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:LESLIE
Last Name:RUCKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 S BROOKSIDE TER
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1210
Mailing Address - Country:US
Mailing Address - Phone:253-448-8690
Mailing Address - Fax:
Practice Address - Street 1:1402 S BROOKSIDE TER
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-1210
Practice Address - Country:US
Practice Address - Phone:253-448-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-11129207R00000X
WA00024572207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine