Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251N0400X | Physical Therapist - Neurology | 40QA01399700 | NJ |
NPI | 1487068524 |
---|---|
Provider Name | Mrs. Jenna Tucker |
First Address | Fair Lawn, NJ 07410-2815 |
Second Address | Fair Lawn, NJ 07410-2815 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2014 |
Last Update Date | 17/06/2014 |