Provider Demographics
NPI:1366819690
Name:TACKETT, JENI DIANE (RD)
Entity Type:Individual
Prefix:MRS
First Name:JENI
Middle Name:DIANE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3928 172ND ST N
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-9728
Mailing Address - Country:US
Mailing Address - Phone:309-230-9517
Mailing Address - Fax:
Practice Address - Street 1:3928 172ND ST N
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-9728
Practice Address - Country:US
Practice Address - Phone:309-230-9517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL876463133V00000X
IA876463133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered