Provider Demographics
NPI:1629743174
Name:SMITH, JESSICA M
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
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 1:4870 HAYGOOD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5300
Mailing Address - Country:US
Mailing Address - Phone:757-499-1290
Mailing Address - Fax:757-499-0958
Practice Address - Street 1:4870 HAYGOOD RD STE 102
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5300
Practice Address - Country:US
Practice Address - Phone:757-499-1290
Practice Address - Fax:757-499-0958
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist