Provider Demographics
NPI:1881821049
Name:SMITH, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2288 AUTUMN FIRE CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-8956
Mailing Address - Country:US
Mailing Address - Phone:702-499-0848
Mailing Address - Fax:
Practice Address - Street 1:2288 AUTUMN FIRE CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-8956
Practice Address - Country:US
Practice Address - Phone:702-499-0848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI0137106H00000X
NV01173106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV01173OtherBOARD OF EXAMINERS FOR MARRIAGE AND FAMILY THERAPISTS
NVMI0137OtherSTATE OF NEVADA BOARD OF MARRIAGE AND FAMILY THERAPIST