Provider Demographics
NPI:1932720273
Name:SMITH, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
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 1:2704 RAYNHAM CT
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MD
Mailing Address - Zip Code:21013-9519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2107 LAUREL BUSH RD STE 102
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-5202
Practice Address - Country:US
Practice Address - Phone:443-371-3233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health