Healthcare Provider Details

I. General information

NPI: 1104018167
Provider Name (Legal Business Name): TRACY M WHITE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY M JASON

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 06/22/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7419 SHALE ROCK RD
PASO ROBLES CA
93446-9378
US

IV. Provider business mailing address

PO BOX 2466
PASO ROBLES CA
93447-2466
US

V. Phone/Fax

Practice location:
  • Phone: 805-610-5561
  • Fax:
Mailing address:
  • Phone: 805-610-5561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP14405
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: