Provider Demographics
NPI:1386646024
Name:SMITH, JENNIFER S (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1612 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6519
Mailing Address - Country:US
Mailing Address - Phone:707-468-9030
Mailing Address - Fax:707-468-4313
Practice Address - Street 1:999 ADAMS ST
Practice Address - Street 2:SUITE D
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-1148
Practice Address - Country:US
Practice Address - Phone:707-965-3658
Practice Address - Fax:707-963-1775
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386646024Medicaid
CA1386646024Medicaid
CABN237ZMedicare PIN
P65612Medicare UPIN