1558370205 NPI number — MRS. JENA NAOMI SMITH NP-C

Table of content: MRS. JENA NAOMI SMITH NP-C (NPI 1558370205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558370205 NPI number — MRS. JENA NAOMI SMITH NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JENA
Provider Middle Name:
NAOMI
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558370205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 DRAPERTON CT
Provider Second Line Business Mailing Address:
PRICE DERMATOLOGY
Provider Business Mailing Address City Name:
RIDGELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39157-3905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-992-3996
Provider Business Mailing Address Fax Number:
601-414-0221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 DRAPERTON CT
Provider Second Line Business Practice Location Address:
PRICE DERMATOLOGY
Provider Business Practice Location Address City Name:
RIDGELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39157-3905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-992-3996
Provider Business Practice Location Address Fax Number:
601-414-0221
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R822693 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04827502 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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