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General NPI Number Information
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NPI Number | 1629701032
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Entity Type | Individual
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Provider Name | JIMMY REECE SMITH
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Gender | Male
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Dates
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Enumeration Date | 07/04/2022
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Last Update Date | 12/04/2024
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Provider Practice Location Address
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Address Line | 384 MOUNT EVEREST WAY
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City | BOWLING GREEN
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State | KY
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Zip | 42104-8569
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Country | US
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Telephone | 615-719-0458
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Fax |
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Provider Business Mailing Address
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Address Line | 1143 FAIRWAY ST STE 103
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City | BOWLING GREEN
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State | KY
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Zip | 42103-2452
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Country | US
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Telephone | 407-347-4536
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 1099382
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 4026120
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License Number State | KY
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