Provider Demographics
NPI:1700550233
Name:SMITH, JESSICA MARIE (MSN, FNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 RATLIFF ST STE A
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-6537
Mailing Address - Country:US
Mailing Address - Phone:601-947-8181
Mailing Address - Fax:
Practice Address - Street 1:92 RATLIFF ST STE A
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6537
Practice Address - Country:US
Practice Address - Phone:601-947-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-07
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904825363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner