Provider Demographics
NPI:1972645562
Name:SMITH, JEFFREY STUART (LAC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:STUART
Last Name:SMITH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7340 CONDALIA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-7905
Mailing Address - Country:US
Mailing Address - Phone:760-369-3156
Mailing Address - Fax:
Practice Address - Street 1:56969 YUCCA TRL STE A
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3797
Practice Address - Country:US
Practice Address - Phone:769-365-5677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6187171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist