Healthcare Provider Details

I. General information

NPI: 1497513857
Provider Name (Legal Business Name): JONATHAN TUCKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 02/12/2026
Certification Date: 02/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 EAST CUTLAR CROSSING UNIT 110
LELAND NC
28451
US

IV. Provider business mailing address

1160 EAST CUTLAR CROSSING UNIT 110
LELAND NC
28451
US

V. Phone/Fax

Practice location:
  • Phone: 910-371-1200
  • Fax:
Mailing address:
  • Phone: 910-371-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberSTUDENT
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: