Provider Demographics
NPI:1780085852
Name:TUCKMAN, ANJANETTE N (LCSW)
Entity type:Individual
Prefix:
First Name:ANJANETTE
Middle Name:N
Last Name:TUCKMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 BENNETT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1007
Mailing Address - Country:US
Mailing Address - Phone:541-556-4606
Mailing Address - Fax:541-403-9893
Practice Address - Street 1:66 CLUB RD STE 120
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2439
Practice Address - Country:US
Practice Address - Phone:541-393-5983
Practice Address - Fax:541-393-5984
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL78881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500726944Medicaid