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NPI Code Detail

MEDICARE: JAELYN NICOLE SMITH

MEDICARE: JAELYN NICOLE SMITH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1285462697
Entity Type Code : Individual
Provider Name (Legal Business Name) : JAELYN NICOLE SMITH
Provider Business Mailing Address
First Line : PO BOX 33568
Second Line :
City : SAN DIEGO
State : CA
Zip : 92163-3568
Country : US
Telephone Number : 855-223-7123
Fax Number : 619-374-7134
Provider Business Practice Location Address
First Line : 15852 GALE AVE
Second Line :
City : HACIENDA HEIGHTS
State : CA
Zip : 91745-1601
Country : US
Telephone Number : 855-223-7123
Fax Number : 619-374-7134
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/25/2024
Last Update Date : 05/29/2026

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