Provider Demographics
NPI:1497904460
Name:JONES, TRACY A (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:JONES
Suffix:
Gender:F
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 1:1415 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4528
Mailing Address - Country:US
Mailing Address - Phone:912-283-0777
Mailing Address - Fax:
Practice Address - Street 1:1415 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4528
Practice Address - Country:US
Practice Address - Phone:912-283-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005130235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000934205EMedicaid