Provider Demographics
NPI:1457644387
Name:SMITH, JESSI M (SLP)
Entity Type:Individual
Prefix:MRS
First Name:JESSI
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-3141
Mailing Address - Country:US
Mailing Address - Phone:631-585-0518
Mailing Address - Fax:
Practice Address - Street 1:15 BEECH ST
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-3141
Practice Address - Country:US
Practice Address - Phone:631-585-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019656235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist