Provider Demographics
NPI:1306367016
Name:SMITH, JERONE I SR (MA, FHD)
Entity Type:Individual
Prefix:MR
First Name:JERONE
Middle Name:I
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:MA, FHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 W YUCCA CT UNIT 309
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-5436
Mailing Address - Country:US
Mailing Address - Phone:520-425-9529
Mailing Address - Fax:
Practice Address - Street 1:6280 E PIMA ST STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3074
Practice Address - Country:US
Practice Address - Phone:520-425-9529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty