Provider Demographics
NPI:1568754687
Name:SMITH, JENNIFER HAWKINS
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HAWKINS
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 1:305 ROSEHILL ACRES
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9425
Mailing Address - Country:US
Mailing Address - Phone:304-444-2757
Mailing Address - Fax:
Practice Address - Street 1:10404 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:MARMET
Practice Address - State:WV
Practice Address - Zip Code:25315-1916
Practice Address - Country:US
Practice Address - Phone:304-949-2838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-08
Last Update Date:2011-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist