Provider Demographics
NPI:1013988013
Name:SMITH, JENNIFER (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3073 WHITE MOUNTAIN HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-7101
Mailing Address - Country:US
Mailing Address - Phone:603-356-5461
Mailing Address - Fax:603-356-9647
Practice Address - Street 1:3073 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-7101
Practice Address - Country:US
Practice Address - Phone:603-356-5461
Practice Address - Fax:603-356-9647
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1889207Q00000X
NH19010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME127770103Medicaid
ME127770103Medicaid
MEME1546Medicare ID - Type Unspecified