Provider Demographics
NPI:1336680925
Name:SMITH, JAMIE (FNP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 VETERANS MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6262
Mailing Address - Country:US
Mailing Address - Phone:618-242-3778
Mailing Address - Fax:
Practice Address - Street 1:4121 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6262
Practice Address - Country:US
Practice Address - Phone:618-242-3778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015749363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209015749OtherAPN LICENSE