Healthcare Provider Details

I. General information

NPI: 1134460058
Provider Name (Legal Business Name): JESSICA ROSE SMITH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2013
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 MISSION ST
SANTA CRUZ CA
95060-3530
US

IV. Provider business mailing address

2025 SOQUEL AVE
SANTA CRUZ CA
95062-1323
US

V. Phone/Fax

Practice location:
  • Phone: 831-458-6300
  • Fax: 831-458-6305
Mailing address:
  • Phone: 831-479-6603
  • Fax: 831-458-6293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A12593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: