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General NPI Number Information
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NPI Number | 1083820088
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Entity Type | Individual
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Provider Name | CAROLYN JEAN TUCKER
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Gender | Female
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Dates
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Enumeration Date | 05/15/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 17 PACIFIC ST
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City | ST AUGUSTINE
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State | FL
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Zip | 32084-2753
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Country | US
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Telephone | 904-501-5771
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Fax |
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Provider Business Mailing Address
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Address Line | 203 PRINCE RD
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-4904
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Country | US
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Telephone | 904-501-5771
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH5404
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MT1868
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License Number State | FL
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