Basic Information
| Provider Information | |||||||||
| NPI: | 1285860593 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMALLS | ||||||||
| FirstName: | JACQUELYNE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2205 N VAN DORN ST | ||||||||
| Address2: | APT. #303 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223041071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037463485 | ||||||||
| FaxNumber: | 7038385070 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 N SAINT ASAPH ST | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223141912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037463485 | ||||||||
| FaxNumber: | 7038385070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 06/02/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 0810004112 | VA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 004945026 | 05 | VA | MEDICAID |