Healthcare Provider Details

I. General information

NPI: 1356630800
Provider Name (Legal Business Name): JACQUELYN RAE SMITH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELYN RAE GARCIA D.O.

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1746 COLE BLVD STE 150
LAKEWOOD CO
80401
US

IV. Provider business mailing address

816 W CANNON ST
FORT WORTH TX
76104-3194
US

V. Phone/Fax

Practice location:
  • Phone: 303-914-8800
  • Fax: 303-716-3777
Mailing address:
  • Phone: 817-321-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberDR.0056367
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberP9572
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberDR.0056367
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: