Healthcare Provider Details

I. General information

NPI: 1689832701
Provider Name (Legal Business Name): JEANETTE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 W ESCALON AVE
FRESNO CA
93704-1408
US

IV. Provider business mailing address

688 W ESCALON AVE
FRESNO CA
93704-1408
US

V. Phone/Fax

Practice location:
  • Phone: 559-438-4749
  • Fax:
Mailing address:
  • Phone: 559-438-4749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number665893
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number665893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: