Provider Demographics
NPI:1073088308
Name:SMITH, JERMAIN M (BEHAVIOR ANALYST)
Entity Type:Individual
Prefix:
First Name:JERMAIN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:BEHAVIOR ANALYST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2088 S PADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8467
Mailing Address - Country:US
Mailing Address - Phone:907-203-1601
Mailing Address - Fax:
Practice Address - Street 1:300 W SWANSON AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6844
Practice Address - Country:US
Practice Address - Phone:907-357-0891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-13
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-18-67793106S00000X
1-21-49303103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician