Provider Demographics
NPI:1265591085
Name:SMYTHE, JACQULINE GAIL (MFC 43231)
Entity type:Individual
Prefix:MRS
First Name:JACQULINE
Middle Name:GAIL
Last Name:SMYTHE
Suffix:
Gender:F
Credentials:MFC 43231
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3542 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-8602
Mailing Address - Country:US
Mailing Address - Phone:707-349-2586
Mailing Address - Fax:707-263-4662
Practice Address - Street 1:55 1ST ST # 305I
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4839
Practice Address - Country:US
Practice Address - Phone:707-349-2586
Practice Address - Fax:707-274-9192
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43231106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265591085Medicaid