Provider Demographics
NPI:1295790020
Name:SMITH STOUT, JENNA LEE (CM)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LEE
Last Name:SMITH STOUT
Suffix:
Gender:F
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 PLAZA RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-2975
Mailing Address - Country:US
Mailing Address - Phone:845-338-5575
Mailing Address - Fax:
Practice Address - Street 1:3457 MAIN ST
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:NY
Practice Address - Zip Code:12484-5612
Practice Address - Country:US
Practice Address - Phone:845-430-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000723367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF000723OtherLICENSE #
NYF000723OtherLICENSE #
NYMEM151Medicare ID - Type Unspecified
NYP39904Medicare UPIN