Provider Demographics
NPI:1790037828
Name:SMITH, JESSE GARLAND
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:GARLAND
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 1:1533 KOCH LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-4852
Mailing Address - Country:US
Mailing Address - Phone:408-898-0478
Mailing Address - Fax:
Practice Address - Street 1:1533 KOCH LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-4852
Practice Address - Country:US
Practice Address - Phone:408-898-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-13
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22635363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical