Provider Demographics
NPI:1982026100
Name:SMITH, JENNIFER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 POINT BREEZE AVE
Mailing Address - Street 2:
Mailing Address - City:BREEZY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11697-1621
Mailing Address - Country:US
Mailing Address - Phone:917-355-2031
Mailing Address - Fax:973-423-9580
Practice Address - Street 1:12904 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-1617
Practice Address - Country:US
Practice Address - Phone:347-523-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015747-1103TC0700X
NJSI1005289103TC0700X
NJ35SI00528900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical