Healthcare Provider Details

I. General information

NPI: 1760182752
Provider Name (Legal Business Name): JANE E SMITH APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11590 W BERNARDO CT STE 120
SAN DIEGO CA
92127-1624
US

IV. Provider business mailing address

11590 W BERNARDO CT STE 120
SAN DIEGO CA
92127-1624
US

V. Phone/Fax

Practice location:
  • Phone: 619-733-6414
  • Fax:
Mailing address:
  • Phone: 908-858-5176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00665000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPCC19315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: