Provider Demographics
NPI:1740795947
Name:SMITH, JACQUELINE SUE (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 N EL SERENO CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-7260
Mailing Address - Country:US
Mailing Address - Phone:480-200-7110
Mailing Address - Fax:
Practice Address - Street 1:6007 E BASELINE RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4801
Practice Address - Country:US
Practice Address - Phone:480-833-3698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-10
Last Update Date:2017-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN186293163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse