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General NPI Number Information
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NPI Number | 1174173371
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Entity Type | Individual
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Provider Name | TRACE JACQUOT
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Gender | Male
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Dates
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Enumeration Date | 09/19/2019
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Last Update Date | 09/19/2019
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Provider Practice Location Address
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Address Line | 4171 WHEATON WAY STE 6
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City | BREMERTON
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State | WA
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Zip | 98310-3603
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Country | US
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Telephone | 360-852-5991
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Fax |
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Provider Business Mailing Address
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Address Line | 11612 NE WARD RD
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City | BRUSH PRAIRIE
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State | WA
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Zip | 98606-7120
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Country | US
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Telephone | 360-852-5991
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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 | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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