Provider Demographics
NPI:1649496399
Name:TACKETT, JERRY LLOYD (IMHC)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LLOYD
Last Name:TACKETT
Suffix:
Gender:M
Credentials:IMHC
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 691114
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32969-1114
Mailing Address - Country:US
Mailing Address - Phone:772-559-8673
Mailing Address - Fax:772-562-9451
Practice Address - Street 1:1145 12TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3718
Practice Address - Country:US
Practice Address - Phone:772-559-8673
Practice Address - Fax:772-562-9451
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health