Provider Demographics
NPI:1043795453
Name:SMITH, JONATHAN LAMONT
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LAMONT
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34015 LYNCROFT ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:591 N. SHAW LN.
Practice Address - Street 2:EAST SHAW HALL E155
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48825
Practice Address - Country:US
Practice Address - Phone:248-227-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MIS530435488908390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty