Provider Demographics
NPI:1255738134
Name:SMITH, JACLYN (MED, ACMHC)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MED, ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 S PARK ST APT 9
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:STE 301
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-322-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9216139-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health