Provider Demographics
NPI:1265500300
Name:SMITH, JACQUELINE (OT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16580 WATERSIDE PL
Mailing Address - Street 2:
Mailing Address - City:HUGHESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20637-2823
Mailing Address - Country:US
Mailing Address - Phone:301-274-9508
Mailing Address - Fax:
Practice Address - Street 1:120 HOSPITAL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4022
Practice Address - Country:US
Practice Address - Phone:410-414-4846
Practice Address - Fax:410-414-4810
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04457225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD606MH211OtherMECICARE PROVIDER ID
MD770428300Medicaid