Provider Demographics
NPI:1043952021
Name:TUCKER, TIMREQUS
Entity type:Individual
Prefix:MR
First Name:TIMREQUS
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 SANFORD RD
Mailing Address - Street 2:
Mailing Address - City:COURTLAND
Mailing Address - State:MS
Mailing Address - Zip Code:38620-9406
Mailing Address - Country:US
Mailing Address - Phone:901-239-1705
Mailing Address - Fax:
Practice Address - Street 1:84 SANFORD RD
Practice Address - Street 2:
Practice Address - City:COURTLAND
Practice Address - State:MS
Practice Address - Zip Code:38620-9406
Practice Address - Country:US
Practice Address - Phone:901-239-1705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool