Provider Demographics
NPI:1326793167
Name:SMITH, JACOB ROBERT
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 E ROCK HAVEN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-4413
Mailing Address - Country:US
Mailing Address - Phone:816-380-3582
Mailing Address - Fax:816-380-6964
Practice Address - Street 1:2820 E ROCK HAVEN RD STE 100
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-4413
Practice Address - Country:US
Practice Address - Phone:816-380-3582
Practice Address - Fax:816-380-6964
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022004495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily