Individual
FREDRICK JASON TACKETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
APS.004051
Contact information
Practice address
323 MARION PIKE STE 1, COAL GROVE, OH 45638-2958
(740) 237-4981
(877) 325-2816
Mailing address
117 N 4TH ST, IRONTON, OH 45638-1403
(740) 442-7016
(877) 325-2816
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
171M00000X
Case Manager/Care Coordinator
—
—
175T00000X
Peer Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0017298
—
OH
Enumeration date
05/15/2023
Last updated
06/12/2023
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