Provider Demographics
NPI:1336379403
Name:TACKER, JACK RONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:RONALD
Last Name:TACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-0127
Mailing Address - Country:US
Mailing Address - Phone:360-779-7500
Mailing Address - Fax:253-288-2203
Practice Address - Street 1:19160 FRONT ST NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370
Practice Address - Country:US
Practice Address - Phone:360-779-7500
Practice Address - Fax:360-626-0600
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028053208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA 47684Medicare UPIN