Provider Demographics
NPI:1942560727
Name:TACKTILL, JORDAN ZANE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:ZANE
Last Name:TACKTILL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 WALNUT AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4723
Mailing Address - Country:US
Mailing Address - Phone:540-344-3668
Mailing Address - Fax:
Practice Address - Street 1:222 WALNUT AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4723
Practice Address - Country:US
Practice Address - Phone:540-344-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3534213ES0103X
VA0103301083213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV9847AMedicare PIN