Provider Demographics
NPI:1457783722
Name:SMITH, JESSICA BRYCE (AAS, PSS, CHW)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:BRYCE
Last Name:SMITH
Suffix:
Gender:F
Credentials:AAS, PSS, CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 CHESHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-5060
Mailing Address - Country:US
Mailing Address - Phone:541-343-2993
Mailing Address - Fax:
Practice Address - Street 1:195 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3408
Practice Address - Country:US
Practice Address - Phone:541-762-4325
Practice Address - Fax:541-684-4156
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR50066493Medicaid