Basic Information
| Provider Information | |||||||||
| NPI: | 1487948154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | TRACIE | ||||||||
| MiddleName: | LASHELLE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | P.T., DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98509 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708849509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257692200 | ||||||||
| FaxNumber: | 2257682185 | ||||||||
| Practice Location | |||||||||
| Address1: | 10101 PARK ROWE AVE | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708101686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257692200 | ||||||||
| FaxNumber: | 2257682185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2011 | ||||||||
| LastUpdateDate: | 03/19/2014 | ||||||||
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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 | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 08369R | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 010349 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 08369R | 01 | LA | P.T. LICENSE | OTHER |