Provider Demographics
NPI:1538918867
Name:TUCKER, IAN DAVID
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:DAVID
Last Name:TUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 E JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-1874
Mailing Address - Country:US
Mailing Address - Phone:870-932-2800
Mailing Address - Fax:870-932-1189
Practice Address - Street 1:837 WILLET RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-393-5335
Practice Address - Fax:870-932-1189
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10088-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker