Provider Demographics
NPI:1023655750
Name:JACOBS, TRACY MICHELLE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:MICHELLE
Last Name:JACOBS
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 1:507 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-1203
Mailing Address - Country:US
Mailing Address - Phone:815-262-4856
Mailing Address - Fax:
Practice Address - Street 1:1658 S IL ROUTE 2
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061-9514
Practice Address - Country:US
Practice Address - Phone:815-732-2499
Practice Address - Fax:815-732-6077
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0217321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical