Provider Demographics
NPI:1871351452
Name:SMITH, JESSICA LILLIAN (NCLCMHC-A: A19821)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LILLIAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:NCLCMHC-A: A19821
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 KINGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7829
Mailing Address - Country:US
Mailing Address - Phone:502-744-8477
Mailing Address - Fax:
Practice Address - Street 1:1113 KINGSWOOD DR
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7829
Practice Address - Country:US
Practice Address - Phone:502-744-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19821101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional