Provider Demographics
NPI:1891071080
Name:SMITH, JESS (PA)
Entity Type:Individual
Prefix:
First Name:JESS
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1247 KAMEHAME DR
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-3506
Mailing Address - Country:US
Mailing Address - Phone:229-326-2581
Mailing Address - Fax:
Practice Address - Street 1:500 ALA MOANA BLVD STE 7-230
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-4987
Practice Address - Country:US
Practice Address - Phone:808-582-0459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007584363A00000X
VA0110007462363A00000X
1098380363A00000X
CA51720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant