Individual ProviderJackie SmithNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersPractice Address215 Central Ave Ste 100, Louisville, KY 40208-1450(502) 588-8720PECOS EnrollmentBased on the most recent information from CMS, provider Jackie Smith is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.Part BMedicare Part BEnrolledHHAHome Health AgencyEnrolledDMEDurable Medical EquipmentEnrolledPMDPower Mobility DeviceEnrolledCMS last updated its PECOS records 3 days ago.Profile DetailsProvider ID1588030688Provider TypeIndividualFull NameSmith, JackieGenderFemaleSole ProprietorNoEnumeration Date8/12/2015Last Updated4/28/2022Contact InformationPractice LocationPractice Address215 Central Ave Ste 100, Louisville, KY 40208-1450Phone(502) 588-8720FaxUnlisted FaxMailing LocationMailing AddressPO Box 909, Louisville, KY 40201-0909PhoneUnlisted PhoneFaxUnlisted FaxProvider TaxonomiesCodeDescriptionLicenseCode363LF0000XPrimaryDescriptionNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersLicense3009478KentuckyCode363LP0808XDescriptionNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersLicense3009478KentuckyProvider IdentifiersIDDescriptionIssuerID7100373600DescriptionMedicaidIssuerUnlistedKentucky