Provider Demographics
NPI:1497024715
Name:JARVIS, TRACEY LENN
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LENN
Last Name:JARVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 S MAIN ST STE 220
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-5436
Mailing Address - Country:US
Mailing Address - Phone:866-874-0036
Mailing Address - Fax:
Practice Address - Street 1:705 S MAIN ST STE 220
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-5436
Practice Address - Country:US
Practice Address - Phone:866-874-0036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist