Provider Demographics
NPI:1407630973
Name:SMITH, JENNIFER (LCDC,SAP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCDC,SAP
Other - Prefix:
Other - First Name:J & S
Other - Middle Name:
Other - Last Name:COUNSELING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:212 LINCOLN LN
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-4016
Mailing Address - Country:US
Mailing Address - Phone:404-576-7590
Mailing Address - Fax:
Practice Address - Street 1:212 LINCOLN LN
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-4016
Practice Address - Country:US
Practice Address - Phone:817-300-9164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15574101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)