Healthcare Provider Details

I. General information

NPI: 1063080125
Provider Name (Legal Business Name): JENNIFER CAROL JOLIAT SMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 EXECUTIVE DR STE P1
SAN DIEGO CA
92121-3021
US

IV. Provider business mailing address

9300 CAMPUS POINT DR # 7745
LA JOLLA CA
92037-1300
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-7729
  • Fax: 858-587-6682
Mailing address:
  • Phone: 858-657-7729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95016014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: