Provider Demographics
NPI:1376956789
Name:TACKETT, JEFFERY RAY (APRN, PPCNP-C)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:RAY
Last Name:TACKETT
Suffix:
Gender:M
Credentials:APRN, PPCNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:
Practice Address - Street 1:2650 N TENAYA WAY STE 308
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1102
Practice Address - Country:US
Practice Address - Phone:702-870-2099
Practice Address - Fax:702-869-5347
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18745363LP0200X
NVAPRN002155363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics