Healthcare Provider Details

I. General information

NPI: 1700035722
Provider Name (Legal Business Name): JENNIFER SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KIRKLAND AVE STE 202
CLINTON NY
13323-1426
US

IV. Provider business mailing address

1 KIRKLAND AVE STE 202
CLINTON NY
13323-1426
US

V. Phone/Fax

Practice location:
  • Phone: 315-381-3402
  • Fax: 315-732-2315
Mailing address:
  • Phone: 315-381-3402
  • Fax: 315-732-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number244012
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: