Healthcare Provider Details

I. General information

NPI: 1952557019
Provider Name (Legal Business Name): JAMI GLYNN TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 LYNCHBURG RD
PILOT MOUNTAIN NC
27041-9326
US

IV. Provider business mailing address

5590 REYNOLDA RD
WINSTON SALEM NC
27106-9694
US

V. Phone/Fax

Practice location:
  • Phone: 336-408-0821
  • Fax: 336-232-1411
Mailing address:
  • Phone: 336-922-0456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number4662
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4662
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: