Provider Demographics
NPI:1720013402
Name:SMITH, JENNIFER M (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:DC
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 11543
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318-1543
Mailing Address - Country:US
Mailing Address - Phone:602-789-8600
Mailing Address - Fax:
Practice Address - Street 1:18275 N 59TH AVE STE F134
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1281
Practice Address - Country:US
Practice Address - Phone:602-789-8600
Practice Address - Fax:602-789-8601
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5840111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ44787Medicaid
AZAZ0937510OtherBLUE CROSS BLUE SHIELD
AZU58499Medicare UPIN
AZ44787Medicaid