=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629880612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA NICOLE SMITH LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2025
-----------------------------------------------------
Last Update Date | 01/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2157 GREENBRIER ST
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25311-9623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-553-0051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 419 SUNNYBROOK DR
-----------------------------------------------------
City | HURRICANE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25526-9331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-420-6133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 0002102832
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------