Healthcare Provider Details

I. General information

NPI: 1699262287
Provider Name (Legal Business Name): MRS. KORI JESSICA SMYTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10620 TREENA ST STE 230
SAN DIEGO CA
92131-1140
US

IV. Provider business mailing address

9735 CAMINITO MOJADO
SAN DIEGO CA
92131-2107
US

V. Phone/Fax

Practice location:
  • Phone: 619-793-2010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: