Individual
KIMBERLY JAN TUCKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.ED., CCC-SLP
Contact information
Practice address
10100 GROOMSBRIDGE RD, JOHNS CREEK, GA 30022-2673
(770) 880-7684
Mailing address
10100 GROOMSBRIDGE RD, JOHNS CREEK, GA 30022-2673
(770) 880-7684
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
PCET001021
GA
235Z00000X
Speech-Language Pathologist
Primary
SLP00006300
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10033374
—
GA
01
—
52703821 002
BLUE CROSS & BLUE SHIELD
GA
05
—
637018452A
—
GA
Enumeration date
08/19/2005
Last updated
05/06/2022
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