Provider Demographics
NPI:1932574969
Name:MAXIE, JENNIFER SMITH (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SMITH
Last Name:MAXIE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:FRIERSON
Mailing Address - State:LA
Mailing Address - Zip Code:71027-1925
Mailing Address - Country:US
Mailing Address - Phone:318-286-7958
Mailing Address - Fax:
Practice Address - Street 1:2920 KNIGHT ST STE 155
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2412
Practice Address - Country:US
Practice Address - Phone:318-213-1804
Practice Address - Fax:318-213-1818
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5556101YM0800X, 101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator