Provider Demographics
NPI:1184794125
Name:TACKETT, JERENY S (BA MHA)
Entity type:Individual
Prefix:
First Name:JERENY
Middle Name:S
Last Name:TACKETT
Suffix:
Gender:M
Credentials:BA MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7160 N MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3151
Mailing Address - Country:US
Mailing Address - Phone:606-657-9988
Mailing Address - Fax:606-653-0691
Practice Address - Street 1:7160 N MAYO TRL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3151
Practice Address - Country:US
Practice Address - Phone:606-657-9988
Practice Address - Fax:606-653-0691
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health