MEDICARE: JESSICA SMITH FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024168811	VA

General Provider Information

NPI Number	:	1639363401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA SMITH FNP

Provider Business Mailing Address
First Line	:	15 E CLAY ST
Second Line	:
City	:	SALEM
State	:	VA
Zip	:	24153-3758
Country	:	US
Telephone Number	:	540-378-0190
Fax Number	:	540-387-0584

Provider Business Practice Location Address
First Line	:	15 E CLAY ST
Second Line	:
City	:	SALEM
State	:	VA
Zip	:	24153-3758
Country	:	US
Telephone Number	:	540-378-0190
Fax Number	:	540-387-0584

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2007
Last Update Date	:	11/04/2011

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