Provider Demographics
NPI:1508291873
Name:JAHNER, TRACE (MS, CF-SLP)
Entity Type:Individual
Prefix:MR
First Name:TRACE
Middle Name:
Last Name:JAHNER
Suffix:
Gender:M
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26934 N 178TH AVE
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85387-1075
Mailing Address - Country:US
Mailing Address - Phone:623-980-4164
Mailing Address - Fax:
Practice Address - Street 1:26934 N 178TH AVE
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85387-1075
Practice Address - Country:US
Practice Address - Phone:623-980-4164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP11455235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ841738Medicaid