Healthcare Provider Details

I. General information

NPI: 1720700875
Provider Name (Legal Business Name): JORDAN SMITH CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 10/30/2022
Certification Date: 10/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 TELEGRAPH AVE
BERKELEY CA
94705-1984
US

IV. Provider business mailing address

1209 34TH ST
OAKLAND CA
94608-4133
US

V. Phone/Fax

Practice location:
  • Phone: 510-280-5543
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberCNM08000
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM08000
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number236287
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: