Provider Demographics
NPI:1255710851
Name:SMITH, JACQUELINE
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
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 1:40 DIMOCK SERVICES
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-0000
Mailing Address - Country:US
Mailing Address - Phone:617-442-8800
Mailing Address - Fax:617-442-6268
Practice Address - Street 1:40 DIMOCK SERVICES
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-0000
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:617-442-6268
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility