Provider Demographics
NPI:1659701811
Name:SMITH, JACQUELYN E (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:E
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 1:8430 WINNETKA AVE UNIT 19
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-1642
Mailing Address - Country:US
Mailing Address - Phone:818-857-7146
Mailing Address - Fax:
Practice Address - Street 1:8430 WINNETKA AVE UNIT 19
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:CA
Practice Address - Zip Code:91306-1642
Practice Address - Country:US
Practice Address - Phone:818-857-7146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-25
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA9040144051041C0700X
CA808091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765Medicaid