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General NPI Number Information
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NPI Number | 1740322619
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Entity Type | Individual
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Provider Name | JEAN MARIE LUCK P.A.
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Gender | Female
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Dates
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Enumeration Date | 02/13/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 33420 ROBINDR.
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City | GREEN VALLEY LAKE
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State | CA
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Zip | 92341-8327
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Country | US
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Telephone | 909-379-9894
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8327
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City | GREEN VALLEY LAKE
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State | CA
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Zip | 92341-8327
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Country | US
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Telephone | 909-379-9894
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | CAPA15505
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License Number State | CA
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