Provider Demographics
NPI:1760414395
Name:SMITH, JEAN D (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 LUCAS ST E
Mailing Address - Street 2:
Mailing Address - City:CASTALIA
Mailing Address - State:OH
Mailing Address - Zip Code:44824-9782
Mailing Address - Country:US
Mailing Address - Phone:419-901-0816
Mailing Address - Fax:
Practice Address - Street 1:313 LUCAS ST E
Practice Address - Street 2:
Practice Address - City:CASTALIA
Practice Address - State:OH
Practice Address - Zip Code:44824-9782
Practice Address - Country:US
Practice Address - Phone:419-901-0816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-1223235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11589618OtherCAQH