Provider Demographics
NPI:1295695773
Name:TACKETT, ALEXA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7259 S BINGHAM JUNCTION BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:216 N THIRD ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6104
Practice Address - Country:US
Practice Address - Phone:805-736-3466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-17
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40203235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist