Provider Demographics
NPI:1194575266
Name:SMITH, JACKALYNN THERESE (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:JACKALYNN
Middle Name:THERESE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:1397 GALLERIA DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-6661
Practice Address - Country:US
Practice Address - Phone:702-436-5800
Practice Address - Fax:702-436-2420
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV816978363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV816978OtherSTATE LICENSE
NV1194575266Medicaid