Provider Demographics
NPI:1629271325
Name:SMITH, JACQUELINE ALICE (LMFT)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ALICE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3665
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-0665
Mailing Address - Country:US
Mailing Address - Phone:510-258-8869
Mailing Address - Fax:800-858-8673
Practice Address - Street 1:81 JACKSON ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-1905
Practice Address - Country:US
Practice Address - Phone:510-258-8869
Practice Address - Fax:800-858-8673
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF47159106H00000X
CA48253106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist