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General NPI Number Information
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NPI Number | 1154960250
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Entity Type | Individual
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Provider Name | JESSICA TRACY LAC
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Gender | Female
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Dates
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Enumeration Date | 01/06/2020
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Last Update Date | 01/06/2020
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Provider Practice Location Address
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Address Line | 21448 N 75TH AVE STE 6
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City | GLENDALE
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State | AZ
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Zip | 85308-5978
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Country | US
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Telephone | 940-631-2629
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Fax |
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Provider Business Mailing Address
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Address Line | 13421 N 43RD AVE APT 3095
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City | PHOENIX
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State | AZ
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Zip | 85029-1042
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Country | US
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Telephone | 940-631-2629
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 18662
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License Number State | AZ
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