Provider Demographics
NPI:1265668669
Name:SMITH-JENKINS, JACQUELINE (LCPC, CADC, CRC,CRSS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SMITH-JENKINS
Suffix:
Gender:F
Credentials:LCPC, CADC, CRC,CRSS
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:SMITH-JENKINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JACQUELINE SMITH-JEN
Mailing Address - Street 1:8137 S MARSHFIELD AVE
Mailing Address - Street 2:P.O. BOX 20965
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-4330
Mailing Address - Country:US
Mailing Address - Phone:773-793-0145
Mailing Address - Fax:773-891-1386
Practice Address - Street 1:8137 S MARSHFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-4330
Practice Address - Country:US
Practice Address - Phone:773-793-0145
Practice Address - Fax:773-891-1386
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-31
Last Update Date:2009-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL26095101YA0400X
IL180.007137101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)