Provider Demographics
NPI:1093251076
Name:SMITH, JESSICA ANN (CRNP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 STAUNTON DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-5604
Mailing Address - Country:US
Mailing Address - Phone:304-269-2022
Mailing Address - Fax:304-269-2037
Practice Address - Street 1:107 STAUNTON DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-5604
Practice Address - Country:US
Practice Address - Phone:304-269-2022
Practice Address - Fax:304-269-2037
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017040363LP2300X
WV75079363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1093251076Medicaid