Provider Demographics
NPI:1184671638
Name:SMITH, JACKIE (ARNP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33601-1289
Mailing Address - Country:US
Mailing Address - Phone:813-844-7968
Mailing Address - Fax:813-844-4049
Practice Address - Street 1:1 TAMPA GENERAL CIR
Practice Address - Street 2:SUITE G415
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-844-7968
Practice Address - Fax:813-844-4049
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1307372363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY086NOtherBLUE CROSS BLUE SHIELD
FL307290800Medicaid