Provider Demographics
NPI:1477142941
Name:SMITH, JENNA NICOLE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MO
Mailing Address - Zip Code:65248-1316
Mailing Address - Country:US
Mailing Address - Phone:916-862-5469
Mailing Address - Fax:
Practice Address - Street 1:411 CENTRAL METHODIST SQ STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MO
Practice Address - Zip Code:65248-1198
Practice Address - Country:US
Practice Address - Phone:660-248-6978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200222742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020022274OtherATHLETIC TRAINER