Healthcare Provider Details

I. General information

NPI: 1568298628
Provider Name (Legal Business Name): JACKIE SMITH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4429 S RIVER BLVD STE B
INDEPENDENCE MO
64055-4659
US

IV. Provider business mailing address

4429 S RIVER BLVD STE B
INDEPENDENCE MO
64055-4659
US

V. Phone/Fax

Practice location:
  • Phone: 816-768-0090
  • Fax: 816-912-1739
Mailing address:
  • Phone: 816-768-0090
  • Fax: 816-912-1739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2018029056
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: