Provider Demographics
NPI:1962276741
Name:SMITH, JACQUANA (MPH, IBCLC)
Entity type:Individual
Prefix:
First Name:JACQUANA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MPH, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:723 E 34TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2939
Practice Address - Country:US
Practice Address - Phone:984-484-4012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAL-139768174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN