Provider Demographics
NPI:1215092895
Name:JERMYN, TRACI SPARKS (SLP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:SPARKS
Last Name:JERMYN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 CHARLOIS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1521
Mailing Address - Country:US
Mailing Address - Phone:336-725-0222
Mailing Address - Fax:336-725-0222
Practice Address - Street 1:185 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1521
Practice Address - Country:US
Practice Address - Phone:336-725-0222
Practice Address - Fax:336-725-0222
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5584235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7886558OtherAETNA
D2281OtherMEDCOST
8300041KOtherMEDICAID CBRS
NC7412019Medicaid
NC13574OtherBCBS
4600072OtherUNITED HEALTHCARE
NC8300041KMedicaid