Basic Information
| Provider Information | |||||||||
| NPI: | 1215092895 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JERMYN | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | SPARKS | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 CHARLOIS BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367250222 | ||||||||
| FaxNumber: | 3367250222 | ||||||||
| Practice Location | |||||||||
| Address1: | 185 CHARLOIS BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367250222 | ||||||||
| FaxNumber: | 3367250222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 5584 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 7886558 | 01 | AETNA | OTHER | D2281 | 01 | MEDCOST | OTHER | 8300041K | 01 | MEDICAID CBRS | OTHER | 7412019 | 05 | NC | MEDICAID | 13574 | 01 | NC | BCBS | OTHER | 4600072 | 01 | UNITED HEALTHCARE | OTHER | 8300041K | 05 | NC | MEDICAID |