Provider Demographics
NPI:1184181174
Name:SMITH, JESSICA M
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
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 1:6312 WOODBINE LN
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-9415
Mailing Address - Country:US
Mailing Address - Phone:908-674-3304
Mailing Address - Fax:
Practice Address - Street 1:1151 POCONO BLVD STE 3
Practice Address - Street 2:
Practice Address - City:MOUNT POCONO
Practice Address - State:PA
Practice Address - Zip Code:18344-1033
Practice Address - Country:US
Practice Address - Phone:570-243-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29569072104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker