Provider Demographics
NPI:1902408727
Name:SMITH, JAQUALYN A
Entity Type:Individual
Prefix:
First Name:JAQUALYN
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7343 S UTICA AVE APT 1214
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 N ASPEN AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-2205
Practice Address - Country:US
Practice Address - Phone:539-777-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician