Provider Demographics
NPI:1053763078
Name:JENSEN, TRACY
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:JENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:JAQUITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10219 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-3361
Mailing Address - Country:US
Mailing Address - Phone:301-514-2539
Mailing Address - Fax:
Practice Address - Street 1:5955 QUINN ORCHARD RD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-6656
Practice Address - Country:US
Practice Address - Phone:301-228-2249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-02
Last Update Date:2016-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06653225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist