Provider Demographics
NPI:1922344142
Name:SMITH, JONATHAN EDWARD (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 N JOSEY LN
Mailing Address - Street 2:STE. 100
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-3159
Mailing Address - Country:US
Mailing Address - Phone:469-892-7500
Mailing Address - Fax:
Practice Address - Street 1:3630 N JOSEY LN
Practice Address - Street 2:STE. 100
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-3159
Practice Address - Country:US
Practice Address - Phone:469-892-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103224235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist