Provider Demographics
NPI:1154436590
Name:JACKSON, TRACY P (MD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 THOMPSON LN STE 22209
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-4692
Mailing Address - Country:US
Mailing Address - Phone:615-322-4311
Mailing Address - Fax:615-322-9089
Practice Address - Street 1:2960 CAMINO DIABLO STE 105
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-3945
Practice Address - Country:US
Practice Address - Phone:800-892-2695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97159207LP2900X, 2083A0300X
NC200300358207LP2900X, 2083A0300X
TN426362083A0300X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I39290Medicare UPIN