Provider Demographics
NPI:1669923207
Name:SMITH, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
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 1:578 N LEAVITT RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1131
Mailing Address - Country:US
Mailing Address - Phone:440-213-0858
Mailing Address - Fax:440-988-1227
Practice Address - Street 1:1120 E BROAD ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6306
Practice Address - Country:US
Practice Address - Phone:440-366-2239
Practice Address - Fax:440-365-1366
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019978363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH537550Medicare PIN