Provider Demographics
NPI:1760269567
Name:TRACY, JESSICA ALICIA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ALICIA
Last Name:TRACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-8143
Mailing Address - Country:US
Mailing Address - Phone:505-604-4368
Mailing Address - Fax:
Practice Address - Street 1:1520 GROVE ST
Practice Address - Street 2:
Practice Address - City:LOUDON
Practice Address - State:TN
Practice Address - Zip Code:37774-1575
Practice Address - Country:US
Practice Address - Phone:865-458-5436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3076224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant