Provider Demographics
NPI:1881190460
Name:JAMISON, TRACI DENISE
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:DENISE
Last Name:JAMISON
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 1:8270 WILLOW OAKS CORPORATE DR FL 3
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4511
Mailing Address - Country:US
Mailing Address - Phone:703-912-4547
Mailing Address - Fax:
Practice Address - Street 1:8270 WILLOW OAKS CORPORATE DR FL 3
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4511
Practice Address - Country:US
Practice Address - Phone:703-912-4547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-06049751041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool