Healthcare Provider Details

I. General information

NPI: 1699808428
Provider Name (Legal Business Name): LAURA JACOBO SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA JACOBO

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 HARBOR BLVD BLDG. E
BELMONT CA
94002-4018
US

IV. Provider business mailing address

310 HARBOR BLVD BLDG. E
BELMONT CA
94002-4018
US

V. Phone/Fax

Practice location:
  • Phone: 650-573-3476
  • Fax:
Mailing address:
  • Phone: 650-573-3476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number88165
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: