Provider Demographics
NPI:1407518566
Name:SMITH, JESSICA S
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10100
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-0008
Mailing Address - Country:US
Mailing Address - Phone:970-874-7681
Mailing Address - Fax:
Practice Address - Street 1:70 STAFFORD LN # NA
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2282
Practice Address - Country:US
Practice Address - Phone:970-874-5777
Practice Address - Fax:970-874-1631
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily