1255612537 NPI number — MS. JEANINE MARIE TACKLA APRN, MSN, A-GNP-C,

Table of content: MS. JEANINE MARIE TACKLA APRN, MSN, A-GNP-C, (NPI 1255612537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255612537 NPI number — MS. JEANINE MARIE TACKLA APRN, MSN, A-GNP-C,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TACKLA
Provider First Name:
JEANINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, MSN, A-GNP-C,
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALKENHORST
Provider Other First Name:
JEANINE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255612537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8408 FORT UNION CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76137-5754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-224-9722
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 MEDICAL CENTER DR STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76234-3844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-626-2110
Provider Business Practice Location Address Fax Number:
940-626-2113
Provider Enumeration Date:
08/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WR0006X , with the licence number:  095692 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: 1114749 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 041214374 . This is a "REGISTERED PROFESSIONAL NURSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 95094533 . This is a "REGISTERED PROFESSIONAL NURSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 095692 . This is a "CNOR, CRNFA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1114749 . This is a "APRN-CNP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 915559 . This is a "REGISTERED PROFESSIONAL NURSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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