MEDICARE: MR. TRACY LAMONT JACKSON

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	101YM0800X	Mental Health Counselor	P019412	NC

General Provider Information

NPI Number	:	1548117013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TRACY LAMONT JACKSON

Provider Business Mailing Address
First Line	:	2032 BRENTWOOD RD APT B
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-3285
Country	:	US
Telephone Number	:	919-995-3185
Fax Number	:

Provider Business Practice Location Address
First Line	:	2032 BRENTWOOD RD APT B
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-3285
Country	:	US
Telephone Number	:	919-995-3185
Fax Number	:

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

Provider Enumeration Date	:	03/13/2026
Last Update Date	:	03/13/2026

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