Provider Demographics
NPI:1588061022
Name:SMITH, JEREMY (LPC)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE BLDG 5
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1282
Mailing Address - Country:US
Mailing Address - Phone:859-233-0444
Mailing Address - Fax:859-977-6346
Practice Address - Street 1:1351 NEWTOWN PIKE BLDG 5
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1282
Practice Address - Country:US
Practice Address - Phone:859-233-0444
Practice Address - Fax:859-977-6346
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-27
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1329103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid