Provider Demographics
NPI:1699808428
Name:SMITH, LAURA JACOBO
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JACOBO
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:JACOBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:310 HARBOR BLVD
Mailing Address - Street 2:BLDG. E
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-4018
Mailing Address - Country:US
Mailing Address - Phone:650-573-3476
Mailing Address - Fax:
Practice Address - Street 1:310 HARBOR BLVD
Practice Address - Street 2:BLDG. E
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-4018
Practice Address - Country:US
Practice Address - Phone:650-573-3476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA88165106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor