Provider Demographics
NPI:1316433543
Name:TUCKER, JENIFER
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JENIFER
Other - Middle Name:
Other - Last Name:TUCKER-BOARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4121 VIA ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-8346
Mailing Address - Country:US
Mailing Address - Phone:318-218-0569
Mailing Address - Fax:
Practice Address - Street 1:4121 VIA ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-8346
Practice Address - Country:US
Practice Address - Phone:318-218-0569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)