Provider Demographics
NPI:1538214044
Name:TACKETT, JACQUELINE (LMFT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1217
Mailing Address - Country:US
Mailing Address - Phone:859-253-1686
Mailing Address - Fax:859-254-2743
Practice Address - Street 1:650 HIGH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1235
Practice Address - Country:US
Practice Address - Phone:859-253-1686
Practice Address - Fax:859-254-2743
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
KY0214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY0454Medicare ID - Type UnspecifiedMEDICARE