Healthcare Provider Details

I. General information

NPI: 1366088981
Provider Name (Legal Business Name): JESSICA ANN SMITH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 10/21/2023
Certification Date: 10/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E RIVER ST
ELYRIA OH
44035-5902
US

IV. Provider business mailing address

630 E RIVER ST
ELYRIA OH
44035-5902
US

V. Phone/Fax

Practice location:
  • Phone: 440-329-7817
  • Fax:
Mailing address:
  • Phone: 440-371-6114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0033586
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number459282
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: