Provider Demographics
NPI:1912791351
Name:TACKER, JONATHAN (MS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:TACKER
Suffix:
Gender:
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 20TH AVE W APT 301
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:IL
Mailing Address - Zip Code:61264-3367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 3RD AVE
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-8840
Practice Address - Country:US
Practice Address - Phone:309-779-2094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health