Provider Demographics
NPI:1881875698
Name:SMITHWICK, JERRIE D (ANP)
Entity type:Individual
Prefix:
First Name:JERRIE
Middle Name:D
Last Name:SMITHWICK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 KNICKERBOCKER RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7610
Mailing Address - Country:US
Mailing Address - Phone:325-949-9555
Mailing Address - Fax:
Practice Address - Street 1:3555 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7610
Practice Address - Country:US
Practice Address - Phone:325-949-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX454614364S00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX454614OtherLICENSE