Basic Information
| Provider Information | |||||||||
| NPI: | 1124601810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 LAKESHORE DR APT C202 | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390476094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788979155 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 NORTH STATE ST. | ||||||||
| Address2: | DEPARTMENT OF MEDICINE | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2021 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | T-4374 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.