Provider Demographics
NPI:1154714285
Name:JARVIS, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:JARVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 HARBOR QUAY
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2023
Mailing Address - Country:US
Mailing Address - Phone:757-318-0157
Mailing Address - Fax:
Practice Address - Street 1:708 HARBOR QUAY
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2023
Practice Address - Country:US
Practice Address - Phone:757-318-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1307103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities