Provider Demographics
NPI:1013136415
Name:TRACEY, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TRACEY
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 MEDICAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK DR
Practice Address - Street 2:SUITE 430
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2982
Practice Address - Country:US
Practice Address - Phone:704-403-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01537208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCO892C489Medicare PIN
FL004265400Medicaid
FLFS385ZMedicare PIN