Provider Demographics
NPI:1992466676
Name:TUCKER, COREY JAMAL
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:JAMAL
Last Name:TUCKER
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 1:1803 ERLEN RD
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1064
Mailing Address - Country:US
Mailing Address - Phone:215-272-8746
Mailing Address - Fax:
Practice Address - Street 1:1803 ERLEN RD
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-1064
Practice Address - Country:US
Practice Address - Phone:215-272-8746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health