Provider Demographics
NPI:1659306488
Name:SMITH, JEFFREY ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3455 POLO RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4828
Mailing Address - Country:US
Mailing Address - Phone:336-354-1171
Mailing Address - Fax:336-768-1860
Practice Address - Street 1:3455 POLO RD
Practice Address - Street 2:SUITE 106
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4828
Practice Address - Country:US
Practice Address - Phone:336-354-1171
Practice Address - Fax:336-768-1860
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC1486103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0444FOtherBCBS