Provider Demographics
NPI:1427157528
Name:SMITH, JERI (LMT)
Entity type:Individual
Prefix:
First Name:JERI
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10710 OLD HIGHWAY 64
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-3587
Mailing Address - Country:US
Mailing Address - Phone:731-658-6113
Mailing Address - Fax:731-645-9885
Practice Address - Street 1:641 E POPLAR AVE
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-1828
Practice Address - Country:US
Practice Address - Phone:731-645-5753
Practice Address - Fax:731-645-9885
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLMT 592106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007934Medicaid