Healthcare Provider Details

I. General information

NPI: 1073007324
Provider Name (Legal Business Name): KAPREISHA D TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date: 03/03/2020
Reactivation Date: 03/20/2020

III. Provider practice location address

1420 KETTNER BLVD
SAN DIEGO CA
92101-2421
US

IV. Provider business mailing address

1420 KETTNER BLVD
SAN DIEGO CA
92101-2421
US

V. Phone/Fax

Practice location:
  • Phone: 619-865-0561
  • Fax:
Mailing address:
  • Phone: 619-865-0561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: