Healthcare Provider Details

I. General information

NPI: 1992824932
Provider Name (Legal Business Name): JONATHAN TUCKER MA, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 LAGRANGE ST STE A
NEWNAN GA
30263-2693
US

IV. Provider business mailing address

113 KESWICK MANOR DR
TYRONE GA
30290-1542
US

V. Phone/Fax

Practice location:
  • Phone: 678-433-6634
  • Fax:
Mailing address:
  • Phone: 336-404-9590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number003450
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001169
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: