Healthcare Provider Details

I. General information

NPI: 1437401809
Provider Name (Legal Business Name): JESSICA SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EXECUTIVE PARK DR NE
ATLANTA GA
30329-2206
US

IV. Provider business mailing address

12 EXECUTIVE PARK DR NE
ATLANTA GA
30329-2206
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-1427
  • Fax:
Mailing address:
  • Phone: 404-778-1427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW005792
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW005561
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: