MEDICARE: JACQUELINE RAE SMITH RBT, QMHPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	0733007985	VA
2	106S00000X	Behavior Technician	RBT21152347	VA

General Provider Information

NPI Number	:	1548924996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE RAE SMITH RBT, QMHPC

Provider Business Mailing Address
First Line	:	1741 HIAWATHA DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-8448
Country	:	US
Telephone Number	:	757-266-3430
Fax Number	:

Provider Business Practice Location Address
First Line	:	1741 HIAWATHA DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-8448
Country	:	US
Telephone Number	:	757-266-3430
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2021
Last Update Date	:	10/22/2021

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