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NPI Code Detail

MEDICARE: MS. JEANINE MARIE TACKLA APRN, MSN, A-GNP-C,

MEDICARE: MS. JEANINE MARIE TACKLA APRN, MSN, A-GNP-C,
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163WR0006XRegistered Nurse First Assistant095692IL
2363LG0600XGerontology Nurse Practitioner1114749TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1041214374OTHERILREGISTERED PROFESSIONAL NURSE
295094533OTHERCAREGISTERED PROFESSIONAL NURSE
3095692OTHERCNOR, CRNFA
41114749OTHERTXAPRN-CNP
5915559OTHERTXREGISTERED PROFESSIONAL NURSE

General Provider Information

NPI Number : 1255612537
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. JEANINE MARIE TACKLA APRN, MSN, A-GNP-C,
Provider Business Mailing Address
First Line : 8408 FORT UNION CT
Second Line :
City : FT WORTH
State : TX
Zip : 76137-5754
Country : US
Telephone Number : 847-224-9722
Fax Number :
Provider Business Practice Location Address
First Line : 800 MEDICAL CENTER DR STE C
Second Line :
City : DECATUR
State : TX
Zip : 76234-3844
Country : US
Telephone Number : 940-626-2110
Fax Number : 940-626-2113
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2011
Last Update Date : 09/14/2023

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