Provider Demographics
NPI:1780119065
Name:SMITH, JENNIFER NICOLE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
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 1:3850 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-1821
Mailing Address - Country:US
Mailing Address - Phone:310-631-8004
Mailing Address - Fax:310-631-5875
Practice Address - Street 1:3850 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-1821
Practice Address - Country:US
Practice Address - Phone:310-631-8004
Practice Address - Fax:310-631-5875
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 106H00000X, 171M00000X
CAAMFT122639101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator