Provider Demographics
NPI:1083498463
Name:TACKETT, JORDAN (RD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14004 HILARO SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206
Mailing Address - Country:US
Mailing Address - Phone:501-860-1015
Mailing Address - Fax:
Practice Address - Street 1:14004 HILARO SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206
Practice Address - Country:US
Practice Address - Phone:501-860-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1875133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered