Healthcare Provider Details

I. General information

NPI: 1386646024
Provider Name (Legal Business Name): JENNIFER S SMITH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 06/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 ADAMS ST SUITE D
SAINT HELENA CA
94574-1148
US

IV. Provider business mailing address

1612 S DORA ST
UKIAH CA
95482-6519
US

V. Phone/Fax

Practice location:
  • Phone: 707-965-3658
  • Fax: 707-963-1775
Mailing address:
  • Phone: 707-468-9030
  • Fax: 707-468-4313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15969
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: