Provider Demographics
NPI:1699081620
Name:SMITH, JESSICA ELIZABETH (FNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ELIZABETH
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 415000 LBX 410604
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37241-0604
Mailing Address - Country:US
Mailing Address - Phone:318-798-4539
Mailing Address - Fax:318-798-4601
Practice Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP # 300
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-6000
Practice Address - Country:US
Practice Address - Phone:318-798-4488
Practice Address - Fax:318-798-4431
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06271363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2121031Medicaid