MEDICARE: MRS. TRACY P JACKSON-BUNN RN

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	163W00000X	Registered Nurse	RN353327L	PA

General Provider Information

NPI Number	:	1568719318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACY P JACKSON-BUNN RN

Provider Business Mailing Address
First Line	:	166 W MAPLEWOOD AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-3307
Country	:	US
Telephone Number	:	215-815-4098
Fax Number	:

Provider Business Practice Location Address
First Line	:	6970 GERMANTOWN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-2114
Country	:	US
Telephone Number	:	215-796-5925
Fax Number	:

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

Provider Enumeration Date	:	08/11/2012
Last Update Date	:	08/11/2012

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