Provider Demographics
NPI:1578743696
Name:SMITH, JAYME VIRGINIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JAYME
Middle Name:VIRGINIA
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65704-0677
Mailing Address - Country:US
Mailing Address - Phone:417-924-2059
Mailing Address - Fax:
Practice Address - Street 1:812 N HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MO
Practice Address - Zip Code:65704-7301
Practice Address - Country:US
Practice Address - Phone:417-924-2059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007033886103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497540005Medicaid
MO224204987Medicare PIN