Provider Demographics
NPI:1629587936
Name:SMITH, JENNIFER ROSE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
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 1:1574 HELMER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48621-9720
Mailing Address - Country:US
Mailing Address - Phone:989-619-3734
Mailing Address - Fax:
Practice Address - Street 1:1840 W HOUGHTON LAKE DR UNIT 2
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-9672
Practice Address - Country:US
Practice Address - Phone:989-202-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician