Basic Information
| Provider Information | |||||||||
| NPI: | 1639396740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | L.I.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 57 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783542700 | ||||||||
| FaxNumber: | 9787404902 | ||||||||
| Practice Location | |||||||||
| Address1: | 57 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783542700 | ||||||||
| FaxNumber: | 9787404902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 111799 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.