Provider Demographics
NPI:1104307982
Name:SMITH, JESSICA MEGAN
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MEGAN
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 1:2059 HIGHWAY 70 W
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-2933
Mailing Address - Country:US
Mailing Address - Phone:870-584-2940
Mailing Address - Fax:
Practice Address - Street 1:2059 HIGHWAY 70 W
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-2933
Practice Address - Country:US
Practice Address - Phone:870-584-2940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator