Healthcare Provider Details

I. General information

NPI: 1336064476
Provider Name (Legal Business Name): TRACIE LOUISE CHANNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 MCKITTERICK AVE
JACKSON OH
45640-1025
US

IV. Provider business mailing address

307 MCKITTERICK AVE
JACKSON OH
45640-1025
US

V. Phone/Fax

Practice location:
  • Phone: 740-988-8823
  • Fax:
Mailing address:
  • Phone: 740-988-8823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License NumberRK078379
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: