Provider Demographics
NPI:1871268995
Name:SMITH, ANNISTINE JADE
Entity type:Individual
Prefix:
First Name:ANNISTINE
Middle Name:JADE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4428 ELK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-9614
Mailing Address - Country:US
Mailing Address - Phone:513-571-4711
Mailing Address - Fax:
Practice Address - Street 1:7250 POE AVE STE 220
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-2687
Practice Address - Country:US
Practice Address - Phone:937-912-3305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2410967104100000X
OH104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker