Provider Demographics
NPI:1902276173
Name:TRACY, JENABELLA D
Entity Type:Individual
Prefix:
First Name:JENABELLA
Middle Name:D
Last Name:TRACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENABELLA
Other - Middle Name:D
Other - Last Name:AUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10108 W LINCROFT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5037
Mailing Address - Country:US
Mailing Address - Phone:208-906-4997
Mailing Address - Fax:
Practice Address - Street 1:10108 W LINCROFT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5037
Practice Address - Country:US
Practice Address - Phone:208-906-4997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program