Provider Demographics
NPI:1467831123
Name:TRACY, JARED (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:TRACY
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 POPLAR DR APT 64
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4677
Mailing Address - Country:US
Mailing Address - Phone:503-939-3445
Mailing Address - Fax:
Practice Address - Street 1:1801 POPLAR DR APT 64
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4677
Practice Address - Country:US
Practice Address - Phone:503-939-3445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist