=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609271089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIKINZIE SMOOT, ND
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2014
-----------------------------------------------------
Last Update Date | 12/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 N 5TH ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97530-9028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-621-1883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 820 N 5TH ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97530-9028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-621-1883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 3095
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------