Provider Demographics
NPI:1578906368
Name:SMITH, JACQUELINE MICHELLE (OTA/L)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 N 33RD PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-9102
Mailing Address - Country:US
Mailing Address - Phone:206-854-8449
Mailing Address - Fax:
Practice Address - Street 1:2005 N 33RD PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-9102
Practice Address - Country:US
Practice Address - Phone:206-854-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00000784224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00000784OtherWASHINGTON STATE LICENSE NUMBER FOR OCCUPATION THERAPY ASSISTANT