Provider Demographics
NPI:1629825823
Name:SMOOT, JESSICA PACKER (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:PACKER
Last Name:SMOOT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 MONAGHAN CT
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8309
Mailing Address - Country:US
Mailing Address - Phone:208-313-6033
Mailing Address - Fax:
Practice Address - Street 1:3820 CRESTWOOD LN
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4979
Practice Address - Country:US
Practice Address - Phone:208-552-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-04
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1861669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine