Provider Demographics
NPI:1184152035
Name:SMITH-TINGLE, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SMITH-TINGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:TINGLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:673 POTOMAC STATION DR NE STE 708
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-1819
Mailing Address - Country:US
Mailing Address - Phone:571-264-8383
Mailing Address - Fax:703-669-4878
Practice Address - Street 1:302 INDUSTRIAL CT SE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-3731
Practice Address - Country:US
Practice Address - Phone:571-264-8383
Practice Address - Fax:703-669-4878
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst