MEDICARE: MRS. TRACY AIDAN BOHANNON M.E.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YM0800X	Mental Health Counselor	MH23300	FL

General Provider Information

NPI Number	:	1023207453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACY AIDAN BOHANNON M.E.D

Provider Business Mailing Address
First Line	:	11461 CONN RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-2167
Country	:	US
Telephone Number	:	904-858-1963
Fax Number	:

Provider Business Practice Location Address
First Line	:	4720 SALISBURY RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6101
Country	:	US
Telephone Number	:	904-206-8405
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2007
Last Update Date	:	09/14/2024

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