Provider Demographics
NPI:1295848091
Name:LE JACQ-SMITH, TIMOTHY DAVID (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DAVID
Last Name:LE JACQ-SMITH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 AIME'S WAY
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790
Mailing Address - Country:US
Mailing Address - Phone:401-243-4199
Mailing Address - Fax:
Practice Address - Street 1:501 ANGELL ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4467
Practice Address - Country:US
Practice Address - Phone:401-243-4199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00764103TC0700X
MA8125103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1034540OtherBEACON HEALTH ID NUMBER
RI410489OtherBLUE CHIP RI PROVIDER ID
RI26545-2OtherBCBSRPROVIDER NUMBERI