Basic Information
Provider Information | |||||||||
NPI: | 1487187845 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TUCKER | ||||||||
FirstName: | JACILYNN | ||||||||
MiddleName: | EILEEN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TUCKER CARRROLL | ||||||||
OtherFirstName: | JACILYNN | ||||||||
OtherMiddleName: | EILEEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 402 S SILVER SPRINGS ROAD | ||||||||
Address2: |   | ||||||||
City: | CAPE GIRARDEAU | ||||||||
State: | MO | ||||||||
PostalCode: | 637037536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5733341100 | ||||||||
FaxNumber: | 5736514345 | ||||||||
Practice Location | |||||||||
Address1: | 309 GARRETT STREET | ||||||||
Address2: |   | ||||||||
City: | FREDERICKTOWN | ||||||||
State: | MO | ||||||||
PostalCode: | 636451084 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5737834014 | ||||||||
FaxNumber: | 5737834572 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2017 | ||||||||
LastUpdateDate: | 11/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2017009209 | MO | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.