Provider Demographics
NPI:1750408902
Name:KAE-SMITH, JASON KENNEDY (LMSW)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:KENNEDY
Last Name:KAE-SMITH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4381 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-8913
Mailing Address - Country:US
Mailing Address - Phone:269-686-2203
Mailing Address - Fax:
Practice Address - Street 1:740 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-2344
Practice Address - Country:US
Practice Address - Phone:616-475-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010815661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical