Provider Demographics
NPI:1679094601
Name:SMITH CHASSE, JESSICA GRACE (FNP-C)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:GRACE
Last Name:SMITH CHASSE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3874 RENEE DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4358
Mailing Address - Country:US
Mailing Address - Phone:843-903-4500
Mailing Address - Fax:
Practice Address - Street 1:3874 RENEE DR UNIT B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4358
Practice Address - Country:US
Practice Address - Phone:843-903-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21070363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1780697151OtherMEDICARE/PRIVATE PAY