Provider Demographics
NPI:1063260172
Name:SMITH, JENNIFER DARLENE (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DARLENE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 ST JOHN RD
Mailing Address - Street 2:
Mailing Address - City:BRAXTON
Mailing Address - State:MS
Mailing Address - Zip Code:39044-9470
Mailing Address - Country:US
Mailing Address - Phone:601-906-3857
Mailing Address - Fax:601-951-8236
Practice Address - Street 1:1814 ST JOHN RD
Practice Address - Street 2:
Practice Address - City:BRAXTON
Practice Address - State:MS
Practice Address - Zip Code:39044-9470
Practice Address - Country:US
Practice Address - Phone:601-906-3857
Practice Address - Fax:601-951-8236
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS875311163WP0808X
MS906848363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health