Provider Demographics
NPI:1578890323
Name:SMITH, JESSICA JUNE (RN, BSN, MSN, NP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:JUNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN, BSN, MSN, NP
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:JUNE
Other - Last Name:PASTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18103 CEDAR ISLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48174-9583
Mailing Address - Country:US
Mailing Address - Phone:734-752-7693
Mailing Address - Fax:
Practice Address - Street 1:12895 DENNISON RD
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-9594
Practice Address - Country:US
Practice Address - Phone:734-752-7693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704253687163W00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1578890323Medicaid