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: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W BROADWAY ST
PRINCETON IN
47670-1142
US

IV. Provider business mailing address

1414 W BROADWAY ST
PRINCETON IN
47670-1142
US

V. Phone/Fax

Practice location:
  • Phone: 812-385-5283
  • Fax: 812-385-5274
Mailing address:
  • Phone: 812-385-5283
  • Fax: 812-385-5274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-031499
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71017893A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-031499
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: