Provider Demographics
NPI:1255983557
Name:SMITH, JENNIFER STEWART (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:STEWART
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5737 E DIETRICH LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-7198
Mailing Address - Country:US
Mailing Address - Phone:337-309-0438
Mailing Address - Fax:
Practice Address - Street 1:500 W MCNEESE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5528
Practice Address - Country:US
Practice Address - Phone:337-474-6161
Practice Address - Fax:337-474-6474
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1894-830AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist