Provider Demographics
NPI:1093221541
Name:SMITH, JESSICA LEIGH (COT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:SMITH
Suffix:
Gender:F
Credentials:COT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 FIR RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:GA
Mailing Address - Zip Code:30217-3976
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:439 FIR RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:GA
Practice Address - Zip Code:30217-3976
Practice Address - Country:US
Practice Address - Phone:470-848-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
176773156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic