Provider Demographics
NPI:1093752065
Name:SMITH, JILLIAN R (CRNA)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3309
Mailing Address - Country:US
Mailing Address - Phone:571-777-5173
Mailing Address - Fax:703-890-2650
Practice Address - Street 1:45 READE PL
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3947
Practice Address - Country:US
Practice Address - Phone:845-431-5629
Practice Address - Fax:703-890-2650
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200360008CRNA367500000X
ME054519367500000X
NY725990367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298058Medicaid
OR115595Medicare ID - Type UnspecifiedMEDICARE PART B ID
OR298058Medicaid