Provider Demographics
NPI:1952071367
Name:SMITH, JALA LATRICE NICOLE
Entity Type:Individual
Prefix:
First Name:JALA
Middle Name:LATRICE NICOLE
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 1:6510 TOWN CENTER DR STE E
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3949 N RIVER RD
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:MI
Practice Address - Zip Code:48623-8856
Practice Address - Country:US
Practice Address - Phone:989-702-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician