Provider Demographics
NPI:1578651261
Name:SMITH, JERRY HOWARD JR (MAC, LPC, LCAS, CCS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:HOWARD
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:MAC, LPC, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 DOVE FIELD CT SE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-9619
Mailing Address - Country:US
Mailing Address - Phone:910-880-9810
Mailing Address - Fax:
Practice Address - Street 1:818 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLADENBORO
Practice Address - State:NC
Practice Address - Zip Code:28320-5970
Practice Address - Country:US
Practice Address - Phone:910-863-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5146101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103024Medicaid