Provider Demographics
NPI:1013586213
Name:TACKETT, TAMRA JO
Entity Type:Individual
Prefix:MS
First Name:TAMRA
Middle Name:JO
Last Name:TACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 WEDDINGTON BRANCH RD STE B
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3296
Mailing Address - Country:US
Mailing Address - Phone:606-637-6377
Mailing Address - Fax:
Practice Address - Street 1:50 WEDDINGTON BRANCH RD STE B
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3296
Practice Address - Country:US
Practice Address - Phone:606-637-6377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY256542104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker