Provider Demographics
NPI:1174937965
Name:SMITH, JACQUELINE ELYSE (MA, LMHC)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ELYSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8351 28TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-4518
Mailing Address - Country:US
Mailing Address - Phone:206-297-0391
Mailing Address - Fax:
Practice Address - Street 1:6869 WOODLAWN AVE NE
Practice Address - Street 2:SUITE 114
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-5469
Practice Address - Country:US
Practice Address - Phone:206-297-0391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60408316101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional