Provider Demographics
NPI:1326129701
Name:SMITH, JEANNINE G (DC)
Entity Type:Individual
Prefix:MRS
First Name:JEANNINE
Middle Name:G
Last Name:SMITH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 E BROADWAY ST.
Mailing Address - Street 2:SUITE #22
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802
Mailing Address - Country:US
Mailing Address - Phone:406-543-9883
Mailing Address - Fax:406-926-1722
Practice Address - Street 1:126 E. BROADWAY ST.
Practice Address - Street 2:SUITE #22
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:406-543-9883
Practice Address - Fax:406-926-1722
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT811111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0164084Medicaid
MT0164073Medicaid
MT41321OtherBCBS
MTM000004381Medicare PIN
MT0164084Medicaid