Provider Demographics
NPI:1558363424
Name:SMITH, JENNIFER KRISTA (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KRISTA
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35000 FORD RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-3719
Mailing Address - Country:US
Mailing Address - Phone:734-721-4700
Mailing Address - Fax:734-721-9186
Practice Address - Street 1:35000 FORD RD
Practice Address - Street 2:SUITE 3
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-3719
Practice Address - Country:US
Practice Address - Phone:734-721-4700
Practice Address - Fax:734-721-9186
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014655207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4758526Medicaid
MI300207909OtherTAX ID
MI0N79680004Medicare ID - Type UnspecifiedMEDICARE
MII35110Medicare UPIN