Provider Demographics
NPI:1912598442
Name:SMITH, JACQUELYN (M ED, LBS)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:M ED, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:PA
Mailing Address - Zip Code:18064-1416
Mailing Address - Country:US
Mailing Address - Phone:610-442-7371
Mailing Address - Fax:
Practice Address - Street 1:224 NAZARETH PIKE UNIT 22A
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18020-9084
Practice Address - Country:US
Practice Address - Phone:610-365-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005242251S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician