Provider Demographics
NPI:1235628785
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:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 PRIMACY PKWY STE 241
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5743
Mailing Address - Country:US
Mailing Address - Phone:901-725-5846
Mailing Address - Fax:
Practice Address - Street 1:1265 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3415
Practice Address - Country:US
Practice Address - Phone:901-725-5846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN189649163W00000X
TN24669367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse