Provider Demographics
NPI:1164961215
Name:SMITH, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5836 JARRETT RD
Mailing Address - Street 2:
Mailing Address - City:EIGHT MILE
Mailing Address - State:AL
Mailing Address - Zip Code:36613-3063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5301 MOFFETT RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36618-2924
Practice Address - Country:US
Practice Address - Phone:251-380-3181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist