Provider Demographics
NPI:1477271484
Name:SMITH, JACLYN MICHAELLE (LLMSW)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MICHAELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 44TH ST SW APT 7
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-4359
Mailing Address - Country:US
Mailing Address - Phone:616-729-3510
Mailing Address - Fax:
Practice Address - Street 1:3584 FAIRLANES AVE SW STE 2
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1583
Practice Address - Country:US
Practice Address - Phone:616-797-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511155751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical