Provider Demographics
NPI:1063287050
Name:SMITH, JACLYN BROOKE (RN, CCM)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:BROOKE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 WINDY HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:SODDY DAISY
Mailing Address - State:TN
Mailing Address - Zip Code:37379-2858
Mailing Address - Country:US
Mailing Address - Phone:423-243-8970
Mailing Address - Fax:877-211-6848
Practice Address - Street 1:374 WINDY HOLLOW LN
Practice Address - Street 2:
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379-2858
Practice Address - Country:US
Practice Address - Phone:423-243-8970
Practice Address - Fax:877-211-6848
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000188383163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management