Provider Demographics
NPI:1578794947
Name:SMITH, JENNY T (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:T
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:TAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6053 MAIN ST STE 110
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-4708
Mailing Address - Country:US
Mailing Address - Phone:972-872-8865
Mailing Address - Fax:
Practice Address - Street 1:6053 MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-4708
Practice Address - Country:US
Practice Address - Phone:972-872-8865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L18012Medicare PIN