Provider Demographics
NPI:1811043011
Name:SMITH, JON LARRY (QMHA)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:LARRY
Last Name:SMITH
Suffix:
Gender:M
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 SE ASH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1449
Mailing Address - Country:US
Mailing Address - Phone:503-232-5651
Mailing Address - Fax:
Practice Address - Street 1:5009 NE KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-1915
Practice Address - Country:US
Practice Address - Phone:503-402-8116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health