Provider Demographics
NPI:1528515483
Name:SMITH, JACKEY (LCSW, PSYD)
Entity type:Individual
Prefix:DR
First Name:JACKEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 PINENUT ST
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561-6343
Mailing Address - Country:US
Mailing Address - Phone:661-917-1415
Mailing Address - Fax:
Practice Address - Street 1:38127 VERSAILLES ST
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93552-3523
Practice Address - Country:US
Practice Address - Phone:661-917-1415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW732181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical