Provider Demographics
NPI:1962144741
Name:TUCKER, ANDRE JEROME SR
Entity type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:JEROME
Last Name:TUCKER
Suffix:SR
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 1:12477 TIERRA BONITA DR
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-7619
Mailing Address - Country:US
Mailing Address - Phone:442-285-8937
Mailing Address - Fax:
Practice Address - Street 1:12477 TIERRA BONITA DR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-7619
Practice Address - Country:US
Practice Address - Phone:442-285-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician