Provider Demographics
NPI:1689832701
Name:SMITH, JEANETTE
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 W ESCALON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-1408
Mailing Address - Country:US
Mailing Address - Phone:559-438-4749
Mailing Address - Fax:
Practice Address - Street 1:688 W ESCALON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-1408
Practice Address - Country:US
Practice Address - Phone:559-438-4749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA665893163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7728336OtherMEDI CAL PIN
CAEPS013980OtherMEDI CAL INP PROVIDER NUMBER