Healthcare Provider Details

I. General information

NPI: 1417021999
Provider Name (Legal Business Name): JENNIFER ANN SMITH M.ED., PCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

453 ALLENBY DR
MARYSVILLE OH
43040-8722
US

IV. Provider business mailing address

5592 CRAWFORD DR
COLUMBUS OH
43229-4176
US

V. Phone/Fax

Practice location:
  • Phone: 937-642-0048
  • Fax: 937-642-1316
Mailing address:
  • Phone: 614-846-6597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE 0501056
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: