Provider Demographics
NPI:1407630973
Name:SMITH, JENNIFER (LCDC,SAP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCDC,SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6008 CASTANADA DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-2235
Mailing Address - Country:US
Mailing Address - Phone:404-576-7590
Mailing Address - Fax:
Practice Address - Street 1:6008 CASTANADA DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-2235
Practice Address - Country:US
Practice Address - Phone:404-576-7590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15574101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)