Provider Demographics
NPI:1275031767
Name:SMITH, JAE (BSW, MATS)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BSW, MATS
Other - Prefix:
Other - First Name:MYCAH
Other - Middle Name:
Other - Last Name:SUTTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:960 E BLACKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-2278
Mailing Address - Country:US
Mailing Address - Phone:812-604-6777
Mailing Address - Fax:
Practice Address - Street 1:4847 E VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2611
Practice Address - Country:US
Practice Address - Phone:866-755-4258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator