Provider Demographics
NPI:1023259603
Name:SMITH, JENNIFER LEE (CNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44610-0426
Mailing Address - Country:US
Mailing Address - Phone:330-893-1318
Mailing Address - Fax:330-893-1485
Practice Address - Street 1:4900 OAK STREET
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:OH
Practice Address - Zip Code:44610-0426
Practice Address - Country:US
Practice Address - Phone:330-893-1318
Practice Address - Fax:330-893-1485
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA10628NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3003556Medicaid
OH3003556Medicaid