Individual
DR. JEFFREY BLAKE LUCKETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PHD
Contact information
Practice address
3635 MANASSAS DR, ROANOKE, VA 24018-4031
(540) 774-4686
(540) 989-8893
Mailing address
3635 MANASSAS DR, ROANOKE, VA 24018-4031
(540) 774-4686
(540) 989-8893
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
0810001414
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
046086
ANTHEM
VA
Enumeration date
09/27/2006
Last updated
01/11/2012
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