Provider Demographics
NPI:1174099170
Name:SMITH, JESSE ENOCH (APRN)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:ENOCH
Last Name:SMITH
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80807-1649
Mailing Address - Country:US
Mailing Address - Phone:719-346-9481
Mailing Address - Fax:719-346-9485
Practice Address - Street 1:182 16TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80807-1649
Practice Address - Country:US
Practice Address - Phone:719-346-9481
Practice Address - Fax:719-346-9485
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN-0994197-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily