Provider Demographics
NPI:1003831504
Name:SMITH, JEFFREY WILLIAM (MFT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:SMITH
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 N MELROSE DR
Mailing Address - Street 2:SUITE J
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-2918
Mailing Address - Country:US
Mailing Address - Phone:760-207-6617
Mailing Address - Fax:
Practice Address - Street 1:1304 N MELROSE DR
Practice Address - Street 2:SUITE J
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-2918
Practice Address - Country:US
Practice Address - Phone:760-207-6617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36687106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist