Provider Demographics
NPI:1316773401
Name:SMITH, JESSICA (LMSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1300
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-1300
Mailing Address - Country:US
Mailing Address - Phone:520-435-9025
Mailing Address - Fax:
Practice Address - Street 1:174 S CORONADO DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-6353
Practice Address - Country:US
Practice Address - Phone:520-442-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-13
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-22220101Y00000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor