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
1	363LG0600X	Gerontology Nurse Practitioner	1114749	TX
2	163WR0006X	Registered Nurse First Assistant	095692	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	041214374	OTHER	IL	REGISTERED PROFESSIONAL NURSE
2	95094533	OTHER	CA	REGISTERED PROFESSIONAL NURSE
3	095692	OTHER		CNOR, CRNFA
4	1114749	OTHER	TX	APRN-CNP
5	915559	OTHER	TX	REGISTERED 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	:	8739 DAVIS BLVD STE 100
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-0309
Country	:	US
Telephone Number	:	817-476-1226
Fax Number	:

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

Provider Enumeration Date	:	08/31/2011
Last Update Date	:	03/17/2026

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