Provider Demographics
NPI:1275181414
Name:JACKSON, TRACIE LATRICE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LATRICE
Last Name:JACKSON
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 1:3620 N RANCHO DR STE 117
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3154
Mailing Address - Country:US
Mailing Address - Phone:725-251-3737
Mailing Address - Fax:725-251-5797
Practice Address - Street 1:1274 CENTER COURT DR STE 211
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3668
Practice Address - Country:US
Practice Address - Phone:909-231-5639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV372600000X, 3747A0650X, 372500000X, 3747P1801X, 376J00000X
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No372500000XNursing Service Related ProvidersChore Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker