Provider Demographics
NPI:1275218596
Name:SMITH, JEANETTE TELLO (LSSP)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:TELLO
Last Name:SMITH
Suffix:
Gender:F
Credentials:LSSP
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:
Other - Last Name:TELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSSP
Mailing Address - Street 1:PO BOX 2603
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2603
Mailing Address - Country:US
Mailing Address - Phone:817-569-4300
Mailing Address - Fax:
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:817-355-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70423103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool