Provider Demographics
NPI:1538560065
Name:SMITH, JENNA WITTE (PA)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:WITTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:WITTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9669 E 146TH ST STE 330
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-5006
Practice Address - Country:US
Practice Address - Phone:317-355-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001726A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005052Medicaid
INP01424309OtherRR MEDICARE
IN300005052Medicaid