Provider Demographics
NPI:1184127904
Name:SMITH, SANDRA JAZMIN (RBT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JAZMIN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16713 VICTORIAN TRL
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-8835
Mailing Address - Country:US
Mailing Address - Phone:209-808-2745
Mailing Address - Fax:
Practice Address - Street 1:1811 GRAND CANAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8107
Practice Address - Country:US
Practice Address - Phone:209-452-8996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-18
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other