Healthcare Provider Details

I. General information

NPI: 1366003840
Provider Name (Legal Business Name): JENNIFER LAUREN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 N 500 W
PROVO UT
84601-1548
US

IV. Provider business mailing address

838 W 2000 N
PROVO UT
84604-1245
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-1801
  • Fax: 12-168-3578
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number10226501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: