Healthcare Provider Details

I. General information

NPI: 1700550233
Provider Name (Legal Business Name): JESSICA MARIE SMITH MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2021
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 RATLIFF ST STE A
LUCEDALE MS
39452-6537
US

IV. Provider business mailing address

92 RATLIFF ST STE A
LUCEDALE MS
39452-6537
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-8181
  • Fax:
Mailing address:
  • Phone: 601-947-8181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number904825
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: