Provider Demographics
NPI:1992379846
Name:SMYTH, JENNIFER RAE (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:SMYTH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11456 CRESTRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-9024
Mailing Address - Country:US
Mailing Address - Phone:773-540-4908
Mailing Address - Fax:
Practice Address - Street 1:11456 CRESTRIDGE CT
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-9024
Practice Address - Country:US
Practice Address - Phone:773-540-4908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-16
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011015221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical