Provider Demographics
NPI:1376554303
Name:SMITH, JACQUELINE RUARK (CRNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RUARK
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 FRONT AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-5364
Mailing Address - Country:US
Mailing Address - Phone:410-296-7190
Mailing Address - Fax:443-991-7768
Practice Address - Street 1:8 DENTON PLZ
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:MD
Practice Address - Zip Code:21629-9501
Practice Address - Country:US
Practice Address - Phone:443-606-2300
Practice Address - Fax:443-606-2305
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR073073363LF0000X
MD032093122363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner