Provider Demographics
NPI:1376335612
Name:SMITH, JACLYN NICOLE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
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 1:214 E MOUNTAIN ST APT J152
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1216
Mailing Address - Country:US
Mailing Address - Phone:646-334-4505
Mailing Address - Fax:
Practice Address - Street 1:1 ASHBURTON PL FL 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-1518
Practice Address - Country:US
Practice Address - Phone:857-214-0518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALSWA416373104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker