Provider Demographics
NPI:1134963507
Name:JACKSON, TRACIE RENEE (RN)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8569 HARVEST VIEW CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6560
Mailing Address - Country:US
Mailing Address - Phone:443-224-5406
Mailing Address - Fax:
Practice Address - Street 1:8569 HARVEST VIEW CT
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6560
Practice Address - Country:US
Practice Address - Phone:443-224-5406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR178169171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator