Provider Demographics
NPI:1942194253
Name:TUCKER, JESSICA NICOLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:LAUVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2605 N KEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4623
Mailing Address - Country:US
Mailing Address - Phone:405-388-8640
Mailing Address - Fax:
Practice Address - Street 1:2605 N KEY BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4623
Practice Address - Country:US
Practice Address - Phone:405-388-8640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist