Healthcare Provider Details

I. General information

NPI: 1154639359
Provider Name (Legal Business Name): GEORGIA JAQUETTE SMITH RN, OCN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 HARDING AVE STE 1
EAU CLAIRE WI
54701-4861
US

IV. Provider business mailing address

1720 HARDING AVE STE 1
EAU CLAIRE WI
54701-4861
US

V. Phone/Fax

Practice location:
  • Phone: 715-461-0463
  • Fax:
Mailing address:
  • Phone: 715-461-0463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number166730-030
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number166730-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: