Healthcare Provider Details

I. General information

NPI: 1184127904
Provider Name (Legal Business Name): SANDRA JAZMIN SMITH RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2018
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 GRAND CANAL BLVD STE 2
STOCKTON CA
95207-8107
US

IV. Provider business mailing address

16713 VICTORIAN TRL
LATHROP CA
95330-8835
US

V. Phone/Fax

Practice location:
  • Phone: 209-452-8996
  • Fax:
Mailing address:
  • Phone: 209-808-2745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: