Provider Demographics
NPI:1255934287
Name:SMITH, JHAIZMINE
Entity type:Individual
Prefix:
First Name:JHAIZMINE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 NE 122ND AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1359
Mailing Address - Country:US
Mailing Address - Phone:503-334-9955
Mailing Address - Fax:
Practice Address - Street 1:333 NE RUSSELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3762
Practice Address - Country:US
Practice Address - Phone:503-334-9955
Practice Address - Fax:833-351-2566
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA10288104100000X, 1041C0700X
ORL116881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker