Provider Demographics
NPI:1720585037
Name:TRACY, JACOB KENNETH (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:KENNETH
Last Name:TRACY
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E LAKE STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770
Mailing Address - Country:US
Mailing Address - Phone:616-889-4104
Mailing Address - Fax:
Practice Address - Street 1:410 E LAKE STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770
Practice Address - Country:US
Practice Address - Phone:616-889-4104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015019101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional