Provider Demographics
NPI:1073640926
Name:SMITH, JACQUELINE ANN (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1916
Mailing Address - Country:US
Mailing Address - Phone:248-548-7206
Mailing Address - Fax:
Practice Address - Street 1:1424 E 11 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2026
Practice Address - Country:US
Practice Address - Phone:248-548-4044
Practice Address - Fax:248-548-9239
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010736921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical