Healthcare Provider Details

I. General information

NPI: 1720013402
Provider Name (Legal Business Name): JENNIFER M SMITH D.C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18275 N 59TH AVE STE F134
GLENDALE AZ
85308-1281
US

IV. Provider business mailing address

PO BOX 11543
GLENDALE AZ
85318-1543
US

V. Phone/Fax

Practice location:
  • Phone: 602-789-8600
  • Fax: 602-789-8601
Mailing address:
  • Phone: 602-789-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5840
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: