Provider Demographics
NPI:1437493525
Name:SMITH, JINGLE DIAZ (LPN)
Entity Type:Individual
Prefix:
First Name:JINGLE
Middle Name:DIAZ
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4498 COUNTRYSIDE CT NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-3196
Mailing Address - Country:US
Mailing Address - Phone:503-983-3400
Mailing Address - Fax:
Practice Address - Street 1:3180 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4532
Practice Address - Country:US
Practice Address - Phone:503-588-5613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201130650LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse