Provider Demographics
NPI:1265024392
Name:SMITH, JACKIE LEA (SLP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LEA
Last Name:SMITH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-4721
Mailing Address - Country:US
Mailing Address - Phone:304-363-7323
Mailing Address - Fax:304-366-2483
Practice Address - Street 1:731 PRESTON DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1545
Practice Address - Country:US
Practice Address - Phone:304-363-7323
Practice Address - Fax:304-366-2483
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-2161235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist