Provider Demographics
NPI:1497034060
Name:SMITH, JACLYN MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WEST 65TH STREET
Mailing Address - Street 2:7TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-6601
Mailing Address - Country:US
Mailing Address - Phone:212-769-7820
Mailing Address - Fax:212-769-7869
Practice Address - Street 1:15 WEST 65TH STREET
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-6601
Practice Address - Country:US
Practice Address - Phone:212-769-7820
Practice Address - Fax:212-769-7869
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0770711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical