Provider Demographics
NPI:1801612957
Name:TACKETT, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 W 79TH PL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5211
Mailing Address - Country:US
Mailing Address - Phone:260-704-1238
Mailing Address - Fax:
Practice Address - Street 1:2924 W 79TH PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5211
Practice Address - Country:US
Practice Address - Phone:260-704-1238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150113687104100000X
IN33012226A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker