Provider Demographics
NPI:1649761107
Name:SMITH, JESSICA LORELLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LORELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LORELLE
Other - Last Name:JUETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:130 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1522
Practice Address - Country:US
Practice Address - Phone:336-777-7239
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-19-39989103K00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health