Provider Demographics
NPI:1053075242
Name:SMITH, JACLYN J
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98577
Mailing Address - Country:US
Mailing Address - Phone:503-791-0096
Mailing Address - Fax:
Practice Address - Street 1:6005 TYEE DR SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7356
Practice Address - Country:US
Practice Address - Phone:360-464-6867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61227019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)