Provider Demographics
NPI:1033293808
Name:TACKETT, PAMELA A (DC)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:A
Last Name:TACKETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1567
Mailing Address - Street 2:1367 E COLLEGE ST
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155
Mailing Address - Country:US
Mailing Address - Phone:830-379-2944
Mailing Address - Fax:830-303-2944
Practice Address - Street 1:1367 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155
Practice Address - Country:US
Practice Address - Phone:830-379-2944
Practice Address - Fax:830-303-2944
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC4350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152916601Medicaid
TX6055551Medicare ID - Type Unspecified
TX152916601Medicaid