Provider Demographics
NPI:1710987771
Name:SMITH, JENNIFER NICOLE (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7222
Mailing Address - Street 2:
Mailing Address - City:KILL DEVIL HILLS
Mailing Address - State:NC
Mailing Address - Zip Code:27948-7222
Mailing Address - Country:US
Mailing Address - Phone:252-216-4462
Mailing Address - Fax:
Practice Address - Street 1:110 W WOOD HILL DR
Practice Address - Street 2:
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-9394
Practice Address - Country:US
Practice Address - Phone:252-216-4462
Practice Address - Fax:252-408-6716
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0049921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003792Medicaid
NC6003792Medicaid
NC141VVOtherHEALTH CHOICE
NC6003792Medicaid
NC6003792Medicaid