Provider Demographics
NPI:1558790469
Name:SMITH, JASON WILLIAM (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:WILLIAM
Last Name:SMITH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-2432
Mailing Address - Country:US
Mailing Address - Phone:515-419-1742
Mailing Address - Fax:
Practice Address - Street 1:201 E 11TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4436
Practice Address - Country:US
Practice Address - Phone:712-262-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00932103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical