Provider Demographics
NPI:1992162556
Name:SMITH, JENNIFER DENINE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DENINE
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 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:523 N US HIGHWAY 1 STE C
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:NC
Practice Address - Zip Code:28379-7771
Practice Address - Country:US
Practice Address - Phone:910-895-2462
Practice Address - Fax:910-895-9896
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCS-8727101YP2500X
NC8727101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional