Provider Demographics
NPI:1285860593
Name:SMALLS, JACQUELYNE M (PSYD)
Entity Type:Individual
Prefix:
First Name:JACQUELYNE
Middle Name:M
Last Name:SMALLS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 N VAN DORN ST
Mailing Address - Street 2:APT. #303
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1071
Mailing Address - Country:US
Mailing Address - Phone:703-746-3485
Mailing Address - Fax:703-838-5070
Practice Address - Street 1:720 N SAINT ASAPH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1912
Practice Address - Country:US
Practice Address - Phone:703-746-3485
Practice Address - Fax:703-838-5070
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004112103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945026Medicaid