Provider Demographics
NPI:1205672615
Name:TACKETT, JACQUELINE A (LPC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:TACKETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12531 CLIPPER DR STE 202-17
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2518
Mailing Address - Country:US
Mailing Address - Phone:571-264-3165
Mailing Address - Fax:
Practice Address - Street 1:14844 ENSOR CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-2676
Practice Address - Country:US
Practice Address - Phone:571-264-3165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-04
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701013686101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional