Provider Demographics
NPI:1891133716
Name:SMITH, JENNIFER BROADWAY (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BROADWAY
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 GREENSBORO STREET EXT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27295-1969
Mailing Address - Country:US
Mailing Address - Phone:336-236-7347
Mailing Address - Fax:
Practice Address - Street 1:264 GREENSBORO STREET EXT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27295-1969
Practice Address - Country:US
Practice Address - Phone:336-236-7347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10089101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101YMO800XOtherMENTAL HEALTH