MEDICARE: MS. TRACY ANN STUCKER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	149-012226	IL

General Provider Information

NPI Number	:	1518022649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TRACY ANN STUCKER LCSW

Provider Business Mailing Address
First Line	:	1515 W WALNUT ST STE 1
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-1159
Country	:	US
Telephone Number	:	217-245-7275
Fax Number	:	217-245-7427

Provider Business Practice Location Address
First Line	:	1515 W WALNUT ST STE 1
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-1159
Country	:	US
Telephone Number	:	217-245-7275
Fax Number	:	217-245-7427

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	04/07/2020

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