Provider Demographics
NPI:1588247753
Name:SMITH, JESSICA LYNNETTE (NNP)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LYNNETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:290 E ROOSEVELT ST APT 414
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-2090
Mailing Address - Country:US
Mailing Address - Phone:801-707-7628
Mailing Address - Fax:
Practice Address - Street 1:1400 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4707
Practice Address - Country:US
Practice Address - Phone:480-412-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7430049-3102163WN0002X
AZ260893363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care