Provider Demographics
NPI:1053595660
Name:SMITH, JACKIE M
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:M
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 1:1942 CRYSTAL SPRINGS RD W
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98466-2910
Mailing Address - Country:US
Mailing Address - Phone:920-471-3419
Mailing Address - Fax:
Practice Address - Street 1:6512 20TH STREET CT W STE B2
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6212
Practice Address - Country:US
Practice Address - Phone:253-468-7899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00055212101Y00000X
WA603361051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor