Provider Demographics
NPI:1760504674
Name:SMITH, JENNIFER MAUNEY (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAUNEY
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28714-3050
Mailing Address - Country:US
Mailing Address - Phone:828-682-2104
Mailing Address - Fax:828-682-4217
Practice Address - Street 1:419 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28714-3050
Practice Address - Country:US
Practice Address - Phone:828-682-2104
Practice Address - Fax:828-682-4217
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2052152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2388088OtherWELLCARE
NC145FKOtherBCBS
NC5907709Medicaid
NC2474432B - NEW BERNMedicare PIN