Provider Demographics
NPI:1306824388
Name:SMITH, JOELLA JACQUELYN (LISW)
Entity Type:Individual
Prefix:MS
First Name:JOELLA
Middle Name:JACQUELYN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:JODI
Other - Middle Name:JACQUELYN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:4403 1ST AVE SE
Mailing Address - Street 2:STE 309
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-3200
Mailing Address - Country:US
Mailing Address - Phone:319-362-0632
Mailing Address - Fax:319-362-5206
Practice Address - Street 1:4403 1ST AVE SE
Practice Address - Street 2:STE 309
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3200
Practice Address - Country:US
Practice Address - Phone:319-362-0632
Practice Address - Fax:319-362-5206
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA013601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
13498OtherWELLMARK
164104OtherVALUE OPTIONS
20032571405OtherJOHN DEERE
6273362OtherUBH
IA0474999Medicaid
2223660OtherFIRST HEALTH
175396OtherMHN
IA0474999Medicaid