Provider Demographics
NPI:1215401112
Name:SMITH, JONATHAN LANG
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LANG
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 1:4112 SHIRLEY DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-4600
Mailing Address - Country:US
Mailing Address - Phone:901-348-9985
Mailing Address - Fax:
Practice Address - Street 1:4112 SHIRLEY DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38109-4600
Practice Address - Country:US
Practice Address - Phone:901-348-9985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist