Provider Demographics
NPI:1134304546
Name:SMITH, JAN E (RD/LD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 W 6TH AVE
Mailing Address - Street 2:BOX 2408
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4306
Mailing Address - Country:US
Mailing Address - Phone:405-742-5458
Mailing Address - Fax:405-742-5697
Practice Address - Street 1:1323 W 6TH AVE
Practice Address - Street 2:BOX 2408
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4306
Practice Address - Country:US
Practice Address - Phone:405-742-5458
Practice Address - Fax:405-742-5697
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1366133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered