Provider Demographics
NPI:1881219442
Name:SMITH, JACALYN SUE
Entity Type:Individual
Prefix:
First Name:JACALYN
Middle Name:SUE
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 1:71268 570TH ST
Mailing Address - Street 2:
Mailing Address - City:GRISWOLD
Mailing Address - State:IA
Mailing Address - Zip Code:51535-6536
Mailing Address - Country:US
Mailing Address - Phone:712-789-0398
Mailing Address - Fax:
Practice Address - Street 1:1905 E 7TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1916
Practice Address - Country:US
Practice Address - Phone:712-243-9223
Practice Address - Fax:712-243-9225
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19471183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist