Provider Demographics
NPI:1639723588
Name:JONES, TRACI MICHELLE (PMHNP - BC)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:MICHELLE
Last Name:JONES
Suffix:
Gender:F
Credentials:PMHNP - BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25353 151ST AVE
Mailing Address - Street 2:
Mailing Address - City:SEBEKA
Mailing Address - State:MN
Mailing Address - Zip Code:56477-2712
Mailing Address - Country:US
Mailing Address - Phone:218-396-0449
Mailing Address - Fax:
Practice Address - Street 1:4 DEERWOOD AVE NW
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1253
Practice Address - Country:US
Practice Address - Phone:218-631-1360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6773363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health