Provider Demographics
NPI:1992422117
Name:SMITH, JESSICA L
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
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 1:191 PIEDMONT AIRLINE RD APT 501
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-8788
Mailing Address - Country:US
Mailing Address - Phone:919-648-3911
Mailing Address - Fax:
Practice Address - Street 1:191 PIEDMONT AIRLINE RD APT 501
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-8788
Practice Address - Country:US
Practice Address - Phone:919-648-3911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician