Provider Demographics
NPI:1821340498
Name:JACKSON, TRACI (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6462 MORRIS RD
Mailing Address - Street 2:
Mailing Address - City:MUNNSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13409
Mailing Address - Country:US
Mailing Address - Phone:315-264-8316
Mailing Address - Fax:
Practice Address - Street 1:6462 MORRIS RD
Practice Address - Street 2:
Practice Address - City:MUNNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13409-4122
Practice Address - Country:US
Practice Address - Phone:315-264-8316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311477164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse