Provider Demographics
NPI:1538481536
Name:TACKETT, JOHN DEWEY
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DEWEY
Last Name:TACKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 SAWMILL PL
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904-1713
Mailing Address - Country:US
Mailing Address - Phone:419-775-8870
Mailing Address - Fax:
Practice Address - Street 1:1817 SAWMILL PL
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44904-1713
Practice Address - Country:US
Practice Address - Phone:419-775-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0900182101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health