MEDICARE: MS. JAIME M TRACY LCSW

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	1041C0700X	Clinical Social Worker	9103186-3501	UT

General Provider Information

NPI Number	:	1548528896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JAIME M TRACY LCSW

Provider Business Mailing Address
First Line	:	517 W 2200 N
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84414-7024
Country	:	US
Telephone Number	:	503-443-0289
Fax Number	:

Provider Business Practice Location Address
First Line	:	1133 N MAIN ST STE 128
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-4830
Country	:	US
Telephone Number	:	801-436-7270
Fax Number	:

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

Provider Enumeration Date	:	04/24/2012
Last Update Date	:	12/06/2019

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