Provider Demographics
NPI:1790112175
Name:SMITH, JIMMY LEE JR (LCSW, LCASA)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:LEE
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:LCSW, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 HOLIDAY LN
Mailing Address - Street 2:
Mailing Address - City:NEWTON GROVE
Mailing Address - State:NC
Mailing Address - Zip Code:28366-6295
Mailing Address - Country:US
Mailing Address - Phone:919-236-9899
Mailing Address - Fax:
Practice Address - Street 1:194 HOLIDAY LN
Practice Address - Street 2:
Practice Address - City:NEWTON GROVE
Practice Address - State:NC
Practice Address - Zip Code:28366-6295
Practice Address - Country:US
Practice Address - Phone:919-236-9899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23353101YA0400X
NCC0104421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)