Individual
MISS TRACIE LASHELLE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.T., DPT
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
010349
GA
225100000X
Physical Therapist
Primary
08369R
LA
225100000X
Physical Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
08369R
P.T. LICENSE
LA
Enumeration date
05/31/2011
Last updated
03/19/2014
Update your record
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