MEDICARE: DR. JACQUELINE BRACY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	C043356	CA

General Provider Information

NPI Number	:	1396806253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE BRACY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1418
Second Line	:	SUITE 324
City	:	GLENDORA
State	:	CA
Zip	:	91740-1418
Country	:	US
Telephone Number	:	626-852-0411
Fax Number	:	626-852-0407

Provider Business Practice Location Address
First Line	:	210 S GRAND AVE
Second Line	:	SUITE 324
City	:	GLENDORA
State	:	CA
Zip	:	91741-4205
Country	:	US
Telephone Number	:	626-852-0411
Fax Number	:	626-852-0407

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	08/30/2016

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