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General NPI Number Information
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NPI Number | 1639387954
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Entity Type | Individual
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Provider Name | BETHANY JAYNE TUCKER M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/18/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 9911 W PICO BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90035-2703
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Country | US
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Telephone | 310-556-0255
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Fax |
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Provider Business Mailing Address
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Address Line | 16622 JOSHUA RD
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City | APPLE VALLEY
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State | CA
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Zip | 92307-1913
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Country | US
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Telephone | 760-247-5410
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | A73695
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License Number State | CA
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