Provider Demographics
NPI:1720678899
Name:SMITH, JESSICA J
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
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 1:501 IDAHO RD
Mailing Address - Street 2:
Mailing Address - City:PALOUSE
Mailing Address - State:WA
Mailing Address - Zip Code:99161-8704
Mailing Address - Country:US
Mailing Address - Phone:406-852-6969
Mailing Address - Fax:
Practice Address - Street 1:501 IDAHO RD
Practice Address - Street 2:
Practice Address - City:PALOUSE
Practice Address - State:WA
Practice Address - Zip Code:99161-8704
Practice Address - Country:US
Practice Address - Phone:406-852-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60909039164W00000X
374J00000X, 174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No374J00000XNursing Service Related ProvidersDoula