Individual
JEREMY SHANE TACKETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
1013 W PARK AVE, CHECOTAH, OK 74426-1250
(918) 473-1748
(918) 473-1748
Mailing address
1013 W PARK AVE, CHECOTAH, OK 74426-1250
(918) 473-1748
(918) 473-1748
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
1335
OK
Other
Enumeration date
05/31/2007
Last updated
07/08/2007
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