Provider Demographics
NPI:1043640162
Name:SMITH, JACQUELYN E (LLMSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22275 GREEN HILL RD APT 26
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-4379
Mailing Address - Country:US
Mailing Address - Phone:313-598-8034
Mailing Address - Fax:
Practice Address - Street 1:22275 GREEN HILL RD APT 26
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-4379
Practice Address - Country:US
Practice Address - Phone:313-598-8034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010917161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical