Provider Demographics
NPI:1891964573
Name:TACKETT-NELSON, REGINA GAYE
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:GAYE
Last Name:TACKETT-NELSON
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 1:366 WASHINGTON ST S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5149
Mailing Address - Country:US
Mailing Address - Phone:503-480-9067
Mailing Address - Fax:
Practice Address - Street 1:821 SAGINAW ST S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4121
Practice Address - Country:US
Practice Address - Phone:503-589-4046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator