Healthcare Provider Details

I. General information

NPI: 1376883488
Provider Name (Legal Business Name): JENNIFER DYANN TUCKER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 NW PRINCESS ST
CORVALLIS OR
97330-3219
US

IV. Provider business mailing address

2650 NW PRINCESS ST
CORVALLIS OR
97330-3219
US

V. Phone/Fax

Practice location:
  • Phone: 503-508-3515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number201243633RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: