Healthcare Provider Details

I. General information

NPI: 1346420809
Provider Name (Legal Business Name): JEFFREY BRIAN SMITH EDD, LBA, BCBA-D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 N PARK LOOP STE 1000
MEMPHIS TN
38152-4869
US

IV. Provider business mailing address

10385 LOBLOLLY VIEW LN
LAKELAND TN
38002-4869
US

V. Phone/Fax

Practice location:
  • Phone: 320-990-1678
  • Fax: 901-678-5630
Mailing address:
  • Phone: 901-488-7830
  • Fax: 901-309-0198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number1-04-1533
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number00010
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: