1023319241 NPI number — JACQULINE SMYTHE

Table of content: (NPI 1023319241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023319241 NPI number — JACQULINE SMYTHE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACQULINE SMYTHE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023319241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3542 CRESTWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KELSEYVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95451-8602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-349-2586
Provider Business Mailing Address Fax Number:
707-263-4662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 1ST ST # 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEPORT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95453-4839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-349-2586
Provider Business Practice Location Address Fax Number:
707-263-4662
Provider Enumeration Date:
11/04/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMYTHE
Authorized Official First Name:
JACQULINE
Authorized Official Middle Name:
GAIL
Authorized Official Title or Position:
MFT
Authorized Official Telephone Number:
707-349-2586

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: MFT43231 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MFT 43231 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".