Provider Demographics
NPI:1235480146
Name:SMITH, JACKIE ANN (LPN)
Entity Type:Individual
Prefix:MISS
First Name:JACKIE
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 AARON DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-3646
Mailing Address - Country:US
Mailing Address - Phone:513-593-5124
Mailing Address - Fax:
Practice Address - Street 1:2065 AARON DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-3646
Practice Address - Country:US
Practice Address - Phone:513-593-5124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN147760164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPN17760MIVOtherOHIO BOARD OF NURSING