Provider Demographics
NPI:1699591925
Name:SMITH, JEREMY L
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 TOWNVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-7223
Mailing Address - Country:US
Mailing Address - Phone:404-989-0524
Mailing Address - Fax:
Practice Address - Street 1:1616 CORNWALL AVE STE 205
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4642
Practice Address - Country:US
Practice Address - Phone:360-676-6177
Practice Address - Fax:360-671-3574
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG61593228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist