Provider Demographics
NPI:1376587600
Name:TACKETT, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:TACKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11675 JOLLYVILLE RD STE 207
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4105
Mailing Address - Country:US
Mailing Address - Phone:512-856-1000
Mailing Address - Fax:317-888-1591
Practice Address - Street 1:11675 JOLLYVILLE RD STE 207
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4105
Practice Address - Country:US
Practice Address - Phone:512-856-1000
Practice Address - Fax:317-888-1591
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000840A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y9381OtherBC/BS
TX8L4066Medicare PIN
TX8Y9381OtherBC/BS