Provider Demographics
NPI:1043412364
Name:TACKETT, JEREMY SHANE (PTA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SHANE
Last Name:TACKETT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHECOTAH
Mailing Address - State:OK
Mailing Address - Zip Code:74426-1250
Mailing Address - Country:US
Mailing Address - Phone:918-473-1748
Mailing Address - Fax:918-473-1748
Practice Address - Street 1:1013 W PARK AVE
Practice Address - Street 2:
Practice Address - City:CHECOTAH
Practice Address - State:OK
Practice Address - Zip Code:74426-1250
Practice Address - Country:US
Practice Address - Phone:918-473-1748
Practice Address - Fax:918-473-1748
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1335225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant