Provider Demographics
NPI:1053192575
Name:SMITH, JACQUELINE LEE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEE
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 1:1921 WOODED TRCE
Mailing Address - Street 2:
Mailing Address - City:OWINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20736-9348
Mailing Address - Country:US
Mailing Address - Phone:410-739-0025
Mailing Address - Fax:
Practice Address - Street 1:10020 SOUTHERN MARYLAND BLVD
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:MD
Practice Address - Zip Code:20754-3031
Practice Address - Country:US
Practice Address - Phone:443-295-3015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician