Provider Demographics
NPI:1083750079
Name:SMITH, JENNIFER LEIGH PERRY (CNM)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH PERRY
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEIGH
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1025 NORTH HOUSTON RD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-1505
Mailing Address - Country:US
Mailing Address - Phone:478-922-9136
Mailing Address - Fax:478-923-6846
Practice Address - Street 1:1025 NORTH HOUSTON RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-1505
Practice Address - Country:US
Practice Address - Phone:478-922-9136
Practice Address - Fax:478-923-6846
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN150993367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA207135713AMedicaid