Provider Demographics
NPI:1760757637
Name:POUNCIE-JAGESSAR, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:POUNCIE-JAGESSAR
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 1:200 WEST CONSTANCE ROAD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434
Mailing Address - Country:US
Mailing Address - Phone:757-803-3129
Mailing Address - Fax:
Practice Address - Street 1:200 WEST CONSTANCE ROAD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8559
Practice Address - Country:US
Practice Address - Phone:757-803-3129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00119004809225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist