Provider Demographics
NPI:1497323695
Name:JACKSON, TRACY
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:
Last Name:JACKSON
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 1:151 KNOCK HILL DR
Mailing Address - Street 2:
Mailing Address - City:ROYERSFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19468-3493
Mailing Address - Country:US
Mailing Address - Phone:484-213-5437
Mailing Address - Fax:
Practice Address - Street 1:151 KNOCK HILL DR
Practice Address - Street 2:
Practice Address - City:ROYERSFORD
Practice Address - State:PA
Practice Address - Zip Code:19468-3493
Practice Address - Country:US
Practice Address - Phone:484-213-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1038809410001251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1038809410001OtherPENNSYLVANIA DEPARTMENT OF HUMAN SERVICES