Provider Demographics
NPI:1992909642
Name:SMITH, JESSICA MAE (LPN)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:MAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 N MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-2515
Mailing Address - Country:US
Mailing Address - Phone:740-418-8498
Mailing Address - Fax:
Practice Address - Street 1:142 N MULBERRY ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2515
Practice Address - Country:US
Practice Address - Phone:740-418-8498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 117012IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse