Provider Demographics
NPI:1306965397
Name:SMITH, JANNE KETTLESON (OD)
Entity type:Individual
Prefix:DR
First Name:JANNE
Middle Name:KETTLESON
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 FREEDOM DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-2818
Mailing Address - Country:US
Mailing Address - Phone:704-392-6371
Mailing Address - Fax:
Practice Address - Street 1:3321 FREEDOM DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-2818
Practice Address - Country:US
Practice Address - Phone:704-392-6371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist