Provider Demographics
NPI:1346310992
Name:SMITH, JENNY GRACE (MD)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:GRACE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2401 WOOTEN BLVD SW STE J
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4464
Mailing Address - Country:US
Mailing Address - Phone:252-237-8403
Mailing Address - Fax:252-237-7443
Practice Address - Street 1:2401 WOOTEN BLVD SW STE J
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4464
Practice Address - Country:US
Practice Address - Phone:252-237-8403
Practice Address - Fax:252-237-7443
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015V1Medicaid
NCH77370Medicare UPIN
NC89015V1Medicaid