Provider Demographics
NPI:1609891282
Name:RICHARDSON-SMITH, JEAN M (PA)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:RICHARDSON-SMITH
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:NAVAL MEDICAL CENTER PORTSMOUTH
Mailing Address - Street 2:620 JOHN PAUL JONES CIRCLE
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23708
Mailing Address - Country:US
Mailing Address - Phone:757-953-2883
Mailing Address - Fax:757-953-0851
Practice Address - Street 1:NAVAL MEDICAL CENTER PORTSMOUTH
Practice Address - Street 2:620 JOHN PAUL JONES CIRCLE
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708
Practice Address - Country:US
Practice Address - Phone:757-953-2883
Practice Address - Fax:757-953-0851
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110840622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010082935Medicaid
MR1085390OtherDEA CERTIFICATE
VA010082935Medicaid
MR1085390OtherDEA CERTIFICATE