Provider Demographics
NPI:1629701032
Name:SMITH, JIMMY REECE
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:REECE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 MOUNT EVEREST WAY
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-8569
Mailing Address - Country:US
Mailing Address - Phone:615-719-0458
Mailing Address - Fax:
Practice Address - Street 1:384 MOUNT EVEREST WAY
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-8569
Practice Address - Country:US
Practice Address - Phone:615-719-0458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1099382163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1099382OtherKY BOARD OF NURSING