Healthcare Provider Details

I. General information

NPI: 1104306034
Provider Name (Legal Business Name): SAMANTHA JADE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N 31ST ST STE 1
MONROE LA
71201-3959
US

IV. Provider business mailing address

895 CLEAR BRANCH RD
FARMERVILLE LA
71241-5043
US

V. Phone/Fax

Practice location:
  • Phone: 318-737-7794
  • Fax:
Mailing address:
  • Phone: 318-235-8769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: