Healthcare Provider Details

I. General information

NPI: 1639396740
Provider Name (Legal Business Name): JESSICA MARY SMITH L.I.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 HIGHLAND AVE
SALEM MA
01970-2141
US

IV. Provider business mailing address

57 HIGHLAND AVE
SALEM MA
01970-2141
US

V. Phone/Fax

Practice location:
  • Phone: 978-354-2700
  • Fax: 978-740-4902
Mailing address:
  • Phone: 978-354-2700
  • Fax: 978-740-4902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111799
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: