MEDICARE: MRS. JESSICA JOHNSON SMITH MSW, LCSW, LCAS, CSI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1104	NC
2	1041C0700X	Clinical Social Worker	C005724	NC

General Provider Information

NPI Number	:	1639360571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA JOHNSON SMITH MSW, LCSW, LCAS, CSI

Provider Business Mailing Address
First Line	:	1288 PARK WEST DR APT 13
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27834-7999
Country	:	US
Telephone Number	:	252-258-8281
Fax Number	:	252-258-8281

Provider Business Practice Location Address
First Line	:	205 PLAZA DR STE D
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-6752
Country	:	US
Telephone Number	:	252-758-1300
Fax Number	:	252-758-0015

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	08/01/2011

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