Healthcare Provider Details

I. General information

NPI: 1629701032
Provider Name (Legal Business Name): JIMMY REECE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2022
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 MOUNT EVEREST WAY
BOWLING GREEN KY
42104-8569
US

IV. Provider business mailing address

1143 FAIRWAY ST STE 103
BOWLING GREEN KY
42103-2452
US

V. Phone/Fax

Practice location:
  • Phone: 615-719-0458
  • Fax:
Mailing address:
  • Phone: 407-347-4536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4026120
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1099382
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: