Provider Demographics
NPI:1356630800
Name:SMITH, JACQUELYN RAE (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:RAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:RAE
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3194
Mailing Address - Country:US
Mailing Address - Phone:817-321-0404
Mailing Address - Fax:
Practice Address - Street 1:1746 COLE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401
Practice Address - Country:US
Practice Address - Phone:303-914-8800
Practice Address - Fax:303-716-3777
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00563672085P0229X, 2085R0202X
TXP95722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology