Provider Demographics
NPI:1952809295
Name:SMITH, JACQUELINE ANNE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANNE
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 1:9490 EMERSON DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8021
Mailing Address - Country:US
Mailing Address - Phone:419-937-7287
Mailing Address - Fax:740-990-0004
Practice Address - Street 1:1012 STATE ROUTE 521 STE 101B
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-8003
Practice Address - Country:US
Practice Address - Phone:740-417-4977
Practice Address - Fax:740-990-0004
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022255363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner