Provider Demographics
NPI:1235834698
Name:TUCKER, DEJANEA
Entity type:Individual
Prefix:
First Name:DEJANEA
Middle Name:
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 1:7751 BELFORT PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6921
Mailing Address - Country:US
Mailing Address - Phone:904-372-3943
Mailing Address - Fax:904-212-1618
Practice Address - Street 1:660 HARRY S TRUMAN DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-2069
Practice Address - Country:US
Practice Address - Phone:301-442-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1046777163W00000X
MDR219532363L00000X, 363LF0000X, 163W00000X
DCNP1046777363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily