Healthcare Provider Details

I. General information

NPI: 1386920767
Provider Name (Legal Business Name): JENNIFER JADE SMITH RPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 W HARVARD AVE STE 432
ROSEBURG OR
97471-8705
US

IV. Provider business mailing address

1813 W HARVARD AVE STE 432
ROSEBURG OR
97471-8705
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-4303
  • Fax:
Mailing address:
  • Phone: 541-673-4303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number106240
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number08OR1342
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: