Provider Demographics
NPI:1336519552
Name:LUCKETT, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:LUCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 N CENTRAL AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2463
Mailing Address - Country:US
Mailing Address - Phone:480-999-4954
Mailing Address - Fax:480-999-4712
Practice Address - Street 1:9200 N CENTRAL AVE STE 2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2463
Practice Address - Country:US
Practice Address - Phone:480-999-4954
Practice Address - Fax:480-999-4712
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8054363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ096036Medicaid