Provider Demographics
NPI:1790209328
Name:SMITH, JACQUELINE ANNETTE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANNETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2491 FOUNTAIN GREENS PL UNIT A-9
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-8639
Mailing Address - Country:US
Mailing Address - Phone:970-210-4241
Mailing Address - Fax:
Practice Address - Street 1:2770 HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81503-2294
Practice Address - Country:US
Practice Address - Phone:970-245-1215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0021807183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist