Provider Demographics
NPI:1053669119
Name:TUCKER, JACKSON SETH (AA)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:SETH
Last Name:TUCKER
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2125
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-2125
Mailing Address - Country:US
Mailing Address - Phone:800-232-5703
Mailing Address - Fax:
Practice Address - Street 1:915 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6614
Practice Address - Country:US
Practice Address - Phone:800-232-5703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00123367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant