Provider Demographics
NPI:1861147506
Name:TACKETT, JASON ADAM
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ADAM
Last Name:TACKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3511
Mailing Address - Country:US
Mailing Address - Phone:801-232-9108
Mailing Address - Fax:
Practice Address - Street 1:831 S GREEN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-3511
Practice Address - Country:US
Practice Address - Phone:801-232-9108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor