Provider Demographics
NPI:1457693194
Name:SMITH, JESSE
Entity Type:Individual
Prefix:MS
First Name:JESSE
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 1:7609 BULL RUN RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20111-1514
Mailing Address - Country:US
Mailing Address - Phone:843-822-1823
Mailing Address - Fax:
Practice Address - Street 1:8140 ASHTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-5698
Practice Address - Country:US
Practice Address - Phone:571-229-1029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005544101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional