Healthcare Provider Details

I. General information

NPI: 1033945134
Provider Name (Legal Business Name): JARVIK LEON TUCKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4202 N I-10 SERVICE RD W
METAIRIE LA
70006
US

IV. Provider business mailing address

350 FAIRWAY DR STE 101
DEERFIELD BCH FL
33441-1834
US

V. Phone/Fax

Practice location:
  • Phone: 927-088-8880
  • Fax:
Mailing address:
  • Phone: 877-418-2978
  • Fax: 866-500-2186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: