Provider Demographics
NPI:1811244817
Name:SMITH, JACQUELYN NORRY (LCSW-R)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:NORRY
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11117 66TH AVENUE #1B
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:617-272-0193
Mailing Address - Fax:
Practice Address - Street 1:1 N BROADWAY
Practice Address - Street 2:SUITE 704
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-2310
Practice Address - Country:US
Practice Address - Phone:617-272-0193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0765921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical