Provider Demographics
NPI:1194869362
Name:TRACY, JANE S (P T)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:S
Last Name:TRACY
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:SHANE
Other - Middle Name:
Other - Last Name:TRACY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:P T
Mailing Address - Street 1:111 RIVERWOODS DR
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:PA
Mailing Address - Zip Code:18938-2226
Mailing Address - Country:US
Mailing Address - Phone:215-862-1135
Mailing Address - Fax:215-862-1135
Practice Address - Street 1:111 RIVERWOODS DR
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:PA
Practice Address - Zip Code:18938-2226
Practice Address - Country:US
Practice Address - Phone:215-862-1135
Practice Address - Fax:215-862-1135
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-002663-L225100000X
NJ40QA00108700225100000X
CA00PT24360225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ110473Medicare PIN
PA109347Medicare PIN