Provider Demographics
NPI:1700542453
Name:SMITH, JESSICA CARMEN (BSN, RN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CARMEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 E LIBERTY LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7864
Mailing Address - Country:US
Mailing Address - Phone:256-601-1944
Mailing Address - Fax:
Practice Address - Street 1:11806 N 87TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-8125
Practice Address - Country:US
Practice Address - Phone:623-487-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC-161397163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse