Provider Demographics
NPI:1760603732
Name:TACKETT, PEGGY JO
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:JO
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 1:4 TERRACE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805
Mailing Address - Country:US
Mailing Address - Phone:419-496-2126
Mailing Address - Fax:
Practice Address - Street 1:4 TERRACE DRIVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805
Practice Address - Country:US
Practice Address - Phone:419-496-2126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2509673374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2509673Medicaid