Provider Demographics
NPI:1124268289
Name:SMITH, JENNIFER MARY (LPN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARY
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10311 PEACOCK LN
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-0877
Mailing Address - Country:US
Mailing Address - Phone:937-301-7687
Mailing Address - Fax:
Practice Address - Street 1:10311 PEACOCK LN
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-0877
Practice Address - Country:US
Practice Address - Phone:937-301-7687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-129060-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse