Provider Demographics
NPI:1154543866
Name:SMITH, JACKIE JR
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9100 BRENTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-4000
Mailing Address - Country:US
Mailing Address - Phone:925-809-7920
Mailing Address - Fax:925-809-7928
Practice Address - Street 1:9100 BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-4000
Practice Address - Country:US
Practice Address - Phone:925-809-7920
Practice Address - Fax:925-809-7928
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA07557OtherDMC ADOL BRENTWOOD
CA0726OtherDRUG M/CAL BILLING NUMBER
CA56681OtherSTAFF ID NUMBER
CA07553OtherBRENTWOOD ADOL TX
CA070726OtherMASTER PROVIDER NUMBER
CA070753OtherMASTER PROVIDER FILE NUMB
CA0753OtherDRUG MEDI-CAL BILLING NO