Healthcare Provider Details

I. General information

NPI: 1609203629
Provider Name (Legal Business Name): JACLYN SMITH CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 OLD HOOK RD
WESTWOOD NJ
07675-3117
US

IV. Provider business mailing address

3 CROSS ST UNIT 202
SUFFERN NY
10901-4622
US

V. Phone/Fax

Practice location:
  • Phone: 201-358-0505
  • Fax: 201-358-1515
Mailing address:
  • Phone: 845-596-4788
  • Fax: 845-357-2495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number25ME00054101
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number25ME00054100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: