Healthcare Provider Details

I. General information

NPI: 1497338453
Provider Name (Legal Business Name): JESSE SMOTHERMAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 VILLAGE ST STE 2
SLIDELL LA
70458-5300
US

IV. Provider business mailing address

112 MAGNOLIA ESTATES DR
LEAGUE CITY TX
77573-4613
US

V. Phone/Fax

Practice location:
  • Phone: 888-606-0086
  • Fax: 346-223-0296
Mailing address:
  • Phone: 888-606-0086
  • Fax: 346-223-0296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1577PL
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1577PL
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: