Provider Demographics
NPI:1275023046
Name:SMITH, JO BARTELL (LPA)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:BARTELL
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7111 LAYLA RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-5428
Mailing Address - Country:US
Mailing Address - Phone:817-371-6275
Mailing Address - Fax:
Practice Address - Street 1:3304 SE LOOP 820
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140-1113
Practice Address - Country:US
Practice Address - Phone:817-984-7545
Practice Address - Fax:817-533-2654
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12629103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12629OtherLICENSED PSYCHOLOGICAL ASSOCIATE - INDEPENDENT PRACTICE