Provider Demographics
NPI:1740985357
Name:SMITH, JESSICA MICHELLE
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MICHELLE
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 1:405 MILL ST
Mailing Address - Street 2:
Mailing Address - City:THERESA
Mailing Address - State:NY
Mailing Address - Zip Code:13691-2229
Mailing Address - Country:US
Mailing Address - Phone:580-222-4680
Mailing Address - Fax:
Practice Address - Street 1:4 FULLER ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA BAY
Practice Address - State:NY
Practice Address - Zip Code:13607-1391
Practice Address - Country:US
Practice Address - Phone:315-482-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist