Basic Information
| Provider Information | |||||||||
| NPI: | 1265417687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | G | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4140 W MEMORIAL RD | ||||||||
| Address2: | SUITE 321 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057484726 | ||||||||
| FaxNumber: | 4056078497 | ||||||||
| Practice Location | |||||||||
| Address1: | 4140 W MEMORIAL RD | ||||||||
| Address2: | SUITE 321 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057484726 | ||||||||
| FaxNumber: | 4056078497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 28110 | OK | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 80768 | 01 | PARTNERS | OTHER | 10186714 | 05 | VA | MEDICAID | 7959719 | 01 | AETNA | OTHER | 200314200A | 05 | OK | MEDICAID | 1391R | 01 | BCBS | OTHER | E4094 | 01 | MEDCOST | OTHER |