Provider Demographics
NPI:1043326580
Name:TACKETT, JASON (DO)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:TACKETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-8768
Mailing Address - Country:US
Mailing Address - Phone:866-638-5931
Mailing Address - Fax:904-805-1456
Practice Address - Street 1:1997 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3811
Practice Address - Country:US
Practice Address - Phone:800-514-1494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008287207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI15511Medicare UPIN