{
"Npi": {
"NPI": "1255612537",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "TACKLA",
"FirstName": "JEANINE",
"MiddleName": "MARIE",
"NamePrefix": "MS.",
"NameSuffix": null,
"Credential": "APRN, MSN, A-GNP-C,",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "WALKENHORST",
"OtherFirstName": "JEANINE",
"OtherMiddleName": "MARIE",
"OtherNamePrefix": "MS.",
"OtherNameSuffix": null,
"OtherCredential": "RN",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "8408 FORT UNION CT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FT WORTH",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "76137-5754",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "847-224-9722",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "800 MEDICAL CENTER DR STE C",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DECATUR",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "76234-3844",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "940-626-2110",
"PracticeLocationAddressFaxNumber": "940-626-2113",
"EnumerationDate": "08/31/2011",
"LastUpdateDate": "09/14/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "163WR0006X",
"TaxonomyName": "Registered Nurse First Assistant",
"LicenseNumber": "095692",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363LG0600X",
"TaxonomyName": "Gerontology Nurse Practitioner",
"LicenseNumber": "1114749",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}