Provider Demographics
NPI:1619445822
Name:SMITH, JONNA
Entity Type:Individual
Prefix:
First Name:JONNA
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:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:CABALLO
Mailing Address - State:NM
Mailing Address - Zip Code:87931-0125
Mailing Address - Country:US
Mailing Address - Phone:575-740-0719
Mailing Address - Fax:
Practice Address - Street 1:312 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-2834
Practice Address - Country:US
Practice Address - Phone:575-740-0719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0197631106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist