Provider Demographics
NPI:1003918319
Name:SMITH, JESSIE DEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:DEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S. 15TH
Mailing Address - Street 2:SUITE C
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-7558
Mailing Address - Fax:208-232-7549
Practice Address - Street 1:115 S. 15TH
Practice Address - Street 2:SUITE C
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-7558
Practice Address - Fax:208-232-7549
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA809111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU59646Medicare UPIN
1673483Medicare PIN
U59646Medicare UPIN