1356630800 NPI number — JACQUELYN RAE SMITH D.O.

Table of content: JACQUELYN RAE SMITH D.O. (NPI 1356630800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356630800 NPI number — JACQUELYN RAE SMITH D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JACQUELYN
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARCIA
Provider Other First Name:
JACQUELYN
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356630800
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
816 W CANNON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-3194
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-321-0404
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1746 COLE BLVD STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-914-8800
Provider Business Practice Location Address Fax Number:
303-716-3777
Provider Enumeration Date:
04/06/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085P0229X , with the licence number:  DR.0056367 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: P9572 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: DR.0056367 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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