Provider Demographics
NPI:1043734122
Name:SMITH, JESSICA CHRISTINE (LMFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:CHRISTINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3460 WASHINGTON DR STE 109
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4301
Mailing Address - Country:US
Mailing Address - Phone:651-412-5088
Mailing Address - Fax:
Practice Address - Street 1:3460 WASHINGTON DR STE 109
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-4301
Practice Address - Country:US
Practice Address - Phone:651-412-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3506106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist