Provider Demographics
NPI:1730667833
Name:TACKITT, JENNIFER MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:TACKITT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15827 E FRIDEGER RD
Mailing Address - Street 2:
Mailing Address - City:ELK
Mailing Address - State:WA
Mailing Address - Zip Code:99009-7009
Mailing Address - Country:US
Mailing Address - Phone:509-292-0417
Mailing Address - Fax:
Practice Address - Street 1:1821 LECLERC RD N STE 1
Practice Address - Street 2:
Practice Address - City:CUSICK
Practice Address - State:WA
Practice Address - Zip Code:99119-5015
Practice Address - Country:US
Practice Address - Phone:509-447-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60883510363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily