Provider Demographics
NPI:1548796162
Name:SMITH, JESSICA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE
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 1:2761 S 114TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-8049
Mailing Address - Country:US
Mailing Address - Phone:918-740-5023
Mailing Address - Fax:
Practice Address - Street 1:2761 S 114TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-8049
Practice Address - Country:US
Practice Address - Phone:918-740-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator