Basic Information
| Provider Information | |||||||||
| NPI: | 1316572258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1330 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TENNESSEE RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371784003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882914357 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1330 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TENNESSEE RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371784003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882914357 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2020 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.