Provider Demographics
NPI:1194870113
Name:SMITH, JANE BANKSTON (LCSW)
Entity type:Individual
Prefix:MS
First Name:JANE
Middle Name:BANKSTON
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:V
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-767-1181
Mailing Address - Fax:225-765-3430
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-767-1181
Practice Address - Fax:225-765-3430
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
5CK45Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER