Provider Demographics
NPI:1386920767
Name:SMITH, JENNIFER JADE (RPA)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:JADE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 W HARVARD AVE STE 432
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8705
Mailing Address - Country:US
Mailing Address - Phone:541-673-4303
Mailing Address - Fax:
Practice Address - Street 1:1813 W HARVARD AVE STE 432
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8705
Practice Address - Country:US
Practice Address - Phone:541-673-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08OR1342243U00000X
OR106240247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist