Provider Demographics
NPI:1861229957
Name:TACKETT, JOHN HOLLIS CROWDER
Entity type:Individual
Prefix:MR
First Name:JOHN HOLLIS
Middle Name:CROWDER
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 1:2500 NORTH STATE STREET
Mailing Address - Street 2:ATTN SCHOOL OF MEDICINE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-984-5012
Mailing Address - Fax:
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:ATTN SCHOOL OF MEDICINE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program