Basic Information
| Provider Information | |||||||||
| NPI: | 1629399373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JOLENE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 ABIGAIL LN | ||||||||
| Address2: | |||||||||
| City: | WAUKEE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502638746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122398673 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12499 UNIVERSITY AVE STE 280 | ||||||||
| Address2: | |||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503258288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152456425 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 01/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 54268 | MN | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 54268 | MN | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | DO-04738 | IA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.