Healthcare Provider Details

I. General information

NPI: 1104455922
Provider Name (Legal Business Name): TUCKER JEPPSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W 3RD ST
MOSCOW ID
83843-2203
US

IV. Provider business mailing address

PO BOX 9583
MOSCOW ID
83843-0177
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-8369
  • Fax:
Mailing address:
  • Phone: 208-882-8369
  • Fax: 208-882-1887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number9861270
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: