Provider Demographics
NPI:1659192730
Name:TRACY, JESSICA LUCILE (LPN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LUCILE
Last Name:TRACY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ASHLAND ST
Mailing Address - Street 2:
Mailing Address - City:KALAMA
Mailing Address - State:WA
Mailing Address - Zip Code:98625-9649
Mailing Address - Country:US
Mailing Address - Phone:360-936-9884
Mailing Address - Fax:
Practice Address - Street 1:305 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1638
Practice Address - Country:US
Practice Address - Phone:360-795-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61461645164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse