Provider Demographics
NPI:1659853729
Name:SMITH, JAMES EDMOND
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDMOND
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12718 N MACARTHUR BLVD APT K
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-2909
Mailing Address - Country:US
Mailing Address - Phone:405-388-9464
Mailing Address - Fax:
Practice Address - Street 1:201 N BROADWAY ST STE 100
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5135
Practice Address - Country:US
Practice Address - Phone:405-990-0816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE