Healthcare Provider Details

I. General information

NPI: 1083820088
Provider Name (Legal Business Name): CAROLYN JEAN TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 PACIFIC ST
ST AUGUSTINE FL
32084-2753
US

IV. Provider business mailing address

203 PRINCE RD
ST AUGUSTINE FL
32086-4904
US

V. Phone/Fax

Practice location:
  • Phone: 904-501-5771
  • Fax:
Mailing address:
  • Phone: 904-501-5771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH5404
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT1868
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: