Provider Demographics
NPI:1104018167
Name:JASON, TRACY M (MA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:JASON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 NACIMIENTO LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446
Mailing Address - Country:US
Mailing Address - Phone:805-610-5561
Mailing Address - Fax:805-733-4392
Practice Address - Street 1:191 WEST BURTON MESA BLVD
Practice Address - Street 2:STE C
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-1400
Practice Address - Country:US
Practice Address - Phone:805-733-4542
Practice Address - Fax:805-733-4392
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP14405235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSP000390Medicaid
CA056582Medicare Oscar/Certification