Provider Demographics
NPI:1265126650
Name:TUCKER, JESSIKA LEE (MS; CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSIKA
Middle Name:LEE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MS; CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 COMMONWEALTH AVE APT 426
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5177
Mailing Address - Country:US
Mailing Address - Phone:704-408-4061
Mailing Address - Fax:
Practice Address - Street 1:4909 WATERS EDGE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-2462
Practice Address - Country:US
Practice Address - Phone:919-285-1647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30001681235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist