Healthcare Provider Details

I. General information

NPI: 1205760576
Provider Name (Legal Business Name): JENNIFER ERIN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 N PENN STATION LN APT 101
MERIDIAN ID
83642-9425
US

IV. Provider business mailing address

1348 N PENN STATION LN APT 101
MERIDIAN ID
83642-9425
US

V. Phone/Fax

Practice location:
  • Phone: 208-473-8436
  • Fax:
Mailing address:
  • Phone: 208-473-8436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberZA116498H
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: