Healthcare Provider Details

I. General information

NPI: 1659162980
Provider Name (Legal Business Name): JENNIFER SMITH APN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 NW 11TH ST
FAIRFIELD IL
62837-1206
US

IV. Provider business mailing address

303 NW 11TH ST
FAIRFIELD IL
62837-1206
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-4617
  • Fax:
Mailing address:
  • Phone: 618-842-4617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-031499
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: