Provider Demographics
NPI:1629653167
Name:TACKETT, CAITLIN
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72201-2220
Mailing Address - Country:US
Mailing Address - Phone:501-794-2463
Mailing Address - Fax:844-605-1515
Practice Address - Street 1:712 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-2220
Practice Address - Country:US
Practice Address - Phone:501-794-2463
Practice Address - Fax:844-605-1515
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health