Healthcare Provider Details

I. General information

NPI: 1346521135
Provider Name (Legal Business Name): JAMEEL MONTGOMERY SMITH PH.D., L.P. NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MACK AVE STE 1
DETROIT MI
48201-2136
US

IV. Provider business mailing address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 313-448-9600
  • Fax:
Mailing address:
  • Phone: 800-653-6568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301019161
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: