Provider Demographics
NPI:1699354415
Name:SMITH, JESSICA LEANE (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 W HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29404-4704
Mailing Address - Country:US
Mailing Address - Phone:843-963-6880
Mailing Address - Fax:
Practice Address - Street 1:204 W HILL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON AFB
Practice Address - State:SC
Practice Address - Zip Code:29404-4704
Practice Address - Country:US
Practice Address - Phone:843-963-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant