Healthcare Provider Details

I. General information

NPI: 1659708436
Provider Name (Legal Business Name): JENNIFER L TUCKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER L STANLEY M.D.

II. Dates (important events)

Enumeration Date: 10/11/2013
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 S ANAHEIM HILLS RD
ANAHEIM CA
92807-4241
US

IV. Provider business mailing address

8078 E SANTA ANA CANYON RD
ANAHEIM CA
92808-1108
US

V. Phone/Fax

Practice location:
  • Phone: 714-282-5437
  • Fax: 714-282-8724
Mailing address:
  • Phone: 714-974-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG66144
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: