Provider Demographics
NPI:1386221042
Name:SMITH, JETTA
Entity Type:Individual
Prefix:
First Name:JETTA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 SPRAGUE ST
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-2024
Mailing Address - Country:US
Mailing Address - Phone:857-389-1224
Mailing Address - Fax:
Practice Address - Street 1:5 CONSTITUTION WAY STE C
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1199
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician