MEDICARE: MR. JOHN DEWEY TACKETT

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
1	101YM0800X	Mental Health Counselor	I.0900182	OH

General Provider Information

NPI Number	:	1538481536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN DEWEY TACKETT

Provider Business Mailing Address
First Line	:	1817 SAWMILL PL
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44904-1713
Country	:	US
Telephone Number	:	419-775-8870
Fax Number	:

Provider Business Practice Location Address
First Line	:	1817 SAWMILL PL
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44904-1713
Country	:	US
Telephone Number	:	419-775-8870
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2010
Last Update Date	:	08/18/2010

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