Provider Demographics
NPI:1629761754
Name:SMITH, JENNIFER ELIZABETH
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
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 1:4 BRANDON LADD CIR
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-3221
Mailing Address - Country:US
Mailing Address - Phone:262-951-5286
Mailing Address - Fax:
Practice Address - Street 1:1751 SHUTTERLEE MILL RD
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-1709
Practice Address - Country:US
Practice Address - Phone:540-332-3934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3001024603103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool