MEDICARE: JENNIFER SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	88533	CA

General Provider Information

NPI Number	:	1548725591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER SMITH

Provider Business Mailing Address
First Line	:	PO BOX 710954
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92171-0954
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4880 LA CUENTA DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-3015
Country	:	US
Telephone Number	:	619-453-2781
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2019
Last Update Date	:	02/04/2019

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