Provider Demographics
NPI:1639363401
Name:SMITH, JESSICA (FNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E CLAY ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-3758
Mailing Address - Country:US
Mailing Address - Phone:540-378-0190
Mailing Address - Fax:540-387-0584
Practice Address - Street 1:15 E CLAY ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3758
Practice Address - Country:US
Practice Address - Phone:540-378-0190
Practice Address - Fax:540-387-0584
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000264901Medicare PIN