Provider Demographics
NPI:1962474486
Name:SMITH, JEAN A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 BARTON DR
Mailing Address - Street 2:
Mailing Address - City:FORDLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65652-7350
Mailing Address - Country:US
Mailing Address - Phone:417-767-2273
Mailing Address - Fax:417-767-4054
Practice Address - Street 1:1059 BARTON DR
Practice Address - Street 2:
Practice Address - City:FORDLAND
Practice Address - State:MO
Practice Address - Zip Code:65652-7350
Practice Address - Country:US
Practice Address - Phone:417-767-2273
Practice Address - Fax:417-767-4054
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO153384163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424622504Medicaid
MO424622504Medicaid