Healthcare Provider Details

I. General information

NPI: 1255612537
Provider Name (Legal Business Name): JEANINE MARIE TACKLA APRN, MSN, A-GNP-C,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JEANINE MARIE WALKENHORST RN

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MEDICAL CENTER DR STE C
DECATUR TX
76234-3844
US

IV. Provider business mailing address

8408 FORT UNION CT
FT WORTH TX
76137-5754
US

V. Phone/Fax

Practice location:
  • Phone: 940-626-2110
  • Fax: 940-626-2113
Mailing address:
  • Phone: 847-224-9722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number095692
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1114749
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: