Provider Demographics
NPI:1023207453
Name:BOHANNON, TRACY AIDAN (MED)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:AIDAN
Last Name:BOHANNON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11461 CONN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-2167
Mailing Address - Country:US
Mailing Address - Phone:904-858-1963
Mailing Address - Fax:
Practice Address - Street 1:4720 SALISBURY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6101
Practice Address - Country:US
Practice Address - Phone:904-206-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH23300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health