Provider Demographics
NPI:1144952201
Name:TUCKER, KENNEDY MASON
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:MASON
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 CHESHIRE RD APT 12B
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-5625
Mailing Address - Country:US
Mailing Address - Phone:614-774-8986
Mailing Address - Fax:
Practice Address - Street 1:61 S STANFIELD RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2992
Practice Address - Country:US
Practice Address - Phone:937-335-3701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker