Provider Demographics
NPI:1720498116
Name:SMITH, JESSICA AMANDA (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:AMANDA
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 E MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2612
Mailing Address - Country:US
Mailing Address - Phone:602-839-2296
Mailing Address - Fax:
Practice Address - Street 1:14406 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1448
Practice Address - Country:US
Practice Address - Phone:503-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1720498116207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology