Healthcare Provider Details

I. General information

NPI: 1336499896
Provider Name (Legal Business Name): JESSICA ANN TRACY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10184 E I25 FRONTAGE RD
FIRESTONE CO
80504-5445
US

IV. Provider business mailing address

604 W WASHINGTON ST STE B
CARSON CITY NV
89703-3828
US

V. Phone/Fax

Practice location:
  • Phone: 954-599-4944
  • Fax:
Mailing address:
  • Phone: 775-882-5001
  • Fax: 775-882-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2795
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT27419
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL0014715
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: