Provider Demographics
NPI:1598135626
Name:SMITH, JESSICA N (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:N
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1281
Mailing Address - Street 2:4TH AND WALNUT ST
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-6937
Mailing Address - Country:US
Mailing Address - Phone:717-269-9405
Mailing Address - Fax:
Practice Address - Street 1:252 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6111
Practice Address - Country:US
Practice Address - Phone:717-270-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003621363A00000X
PAMA057813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant