Provider Demographics
NPI:1699454645
Name:SMITH, JESSICA AZELL
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:AZELL
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5160 VILLAGE CREEK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-4423
Mailing Address - Country:US
Mailing Address - Phone:682-324-9376
Mailing Address - Fax:
Practice Address - Street 1:5160 VILLAGE CREEK DR STE 200
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4423
Practice Address - Country:US
Practice Address - Phone:682-324-9376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician