Provider Demographics
NPI:1689899965
Name:SMITH, JENNIFER SUSANNE (PCC, LICDC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PCC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 SCOTTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43610-1324
Mailing Address - Country:US
Mailing Address - Phone:419-509-6592
Mailing Address - Fax:419-244-5794
Practice Address - Street 1:3454 OAK ALLEY CT
Practice Address - Street 2:SUITE 404
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1306
Practice Address - Country:US
Practice Address - Phone:419-531-3337
Practice Address - Fax:419-531-3302
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0004340101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health