Provider Demographics
NPI:1881208437
Name:TACKITT, JENNIFER CLAIRE (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CLAIRE
Last Name:TACKITT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 INDIANAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-1271
Mailing Address - Country:US
Mailing Address - Phone:317-383-7097
Mailing Address - Fax:
Practice Address - Street 1:561 INDIANAPOLIS RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1271
Practice Address - Country:US
Practice Address - Phone:317-383-7097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007261A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical