Provider Demographics
NPI:1174757066
Name:SMITH, JENNIFER DAWN (PSYD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DAWN
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:3333 BURNET AVENUE
Mailing Address - Street 2:ML 4002
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3039
Mailing Address - Country:US
Mailing Address - Phone:513-636-4611
Mailing Address - Fax:513-636-3800
Practice Address - Street 1:3333 BURNET AVENUE
Practice Address - Street 2:ML 4002
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3039
Practice Address - Country:US
Practice Address - Phone:513-636-4611
Practice Address - Fax:513-636-3800
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6250103T00000X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103T00000XBehavioral Health & Social Service ProvidersPsychologist