MEDICARE: JUANITA TUCKER QMHP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	1041C0700X	Clinical Social Worker	L4517	OR

General Provider Information

NPI Number	:	1114092145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUANITA TUCKER QMHP

Provider Business Mailing Address
First Line	:	4216 NE RODNEY AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-3428
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3034 NE M L KING BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-3053
Country	:	US
Telephone Number	:	503-283-3763
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	12/21/2012

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Directions to “ JUANITA TUCKER QMHP” Practice Location

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