Provider Demographics
NPI:1790419075
Name:JENKINS, TRACY JOSEPH (CEO)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:JOSEPH
Last Name:JENKINS
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6529 N WOODSTOCK ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-3114
Mailing Address - Country:US
Mailing Address - Phone:267-345-5968
Mailing Address - Fax:
Practice Address - Street 1:6529 N WOODSTOCK ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-3114
Practice Address - Country:US
Practice Address - Phone:267-345-5968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA22428191172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver