Provider Demographics
NPI:1992494587
Name:RUCKER, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:RUCKER
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 1:414 N 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-1717
Mailing Address - Country:US
Mailing Address - Phone:541-809-8622
Mailing Address - Fax:
Practice Address - Street 1:414 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-1717
Practice Address - Country:US
Practice Address - Phone:541-809-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver