Provider Demographics
NPI:1982494522
Name:JACKSON, TRACIE R (PRS)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9186 BLUERIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41017
Mailing Address - Country:US
Mailing Address - Phone:859-912-5618
Mailing Address - Fax:
Practice Address - Street 1:9186 BLUERIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-912-5618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist