Provider Demographics
NPI:1225126881
Name:SMITH, PATRICK O (PHD)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:O
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4999
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4999
Mailing Address - Country:US
Mailing Address - Phone:601-984-5410
Mailing Address - Fax:601-815-3771
Practice Address - Street 1:878 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4644
Practice Address - Country:US
Practice Address - Phone:601-984-6800
Practice Address - Fax:601-984-6812
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS32-480103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03537326Medicaid
MS680008706Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MS512I680009Medicare PIN
MSS01470Medicare UPIN
MS680000105Medicare ID - Type Unspecified
MS302I688828Medicare PIN