Provider Demographics
NPI:1346509510
Name:SMITH, JACQUELYN J (PHD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:B510
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-2932
Mailing Address - Fax:414-266-3735
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:B510
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2932
Practice Address - Fax:414-266-3735
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3053-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1346509510Medicaid