Provider Demographics
NPI:1477986685
Name:TRACY, JOLYNN (CADC)
Entity Type:Individual
Prefix:MS
First Name:JOLYNN
Middle Name:
Last Name:TRACY
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 W STOREY ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1496
Mailing Address - Country:US
Mailing Address - Phone:208-898-0315
Mailing Address - Fax:
Practice Address - Street 1:508 E. FLORIDA
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5823
Practice Address - Country:US
Practice Address - Phone:208-463-0118
Practice Address - Fax:208-463-1507
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)