Basic Information
| Provider Information | |||||||||
| NPI: | 1518269331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1237 W DIVIDE AVE | ||||||||
| Address2: | STE 5 | ||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585011208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013288888 | ||||||||
| FaxNumber: | 7013288900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1237 W DIVIDE AVE | ||||||||
| Address2: | STE 5 | ||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585011208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013288888 | ||||||||
| FaxNumber: | 7013288900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2010 | ||||||||
| LastUpdateDate: | 04/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | ND | N | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.