Provider Demographics
NPI:1902028921
Name:SMITH, JAMIE SUE (MED)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:SUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 S WALKUP DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-8531
Mailing Address - Country:US
Mailing Address - Phone:928-773-7959
Mailing Address - Fax:
Practice Address - Street 1:3500 S GILLENWATER DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-9004
Practice Address - Country:US
Practice Address - Phone:928-773-4003
Practice Address - Fax:928-773-4010
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool