Provider Demographics
NPI:1669566105
Name:SMITH, JENNIE
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1209
Mailing Address - Street 2:WARM SPRINGS HEALTH AND WELLNESS CENTER
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97741
Mailing Address - Country:US
Mailing Address - Phone:541-553-2478
Mailing Address - Fax:
Practice Address - Street 1:1270 KOTNUM ROAD
Practice Address - Street 2:WARM SPRINGS HEALTH AND WELLNESS CENTER
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97741
Practice Address - Country:US
Practice Address - Phone:541-553-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000028103N1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP33778Medicare UPIN
OR8HE625Medicare ID - Type UnspecifiedMEDICARE NUMBER