Provider Demographics
NPI:1215408315
Name:SMITH, JENNIFER NICOLE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 ROSEMONT DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6133
Mailing Address - Country:US
Mailing Address - Phone:706-570-0759
Mailing Address - Fax:
Practice Address - Street 1:5001 ROSEMONT DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6133
Practice Address - Country:US
Practice Address - Phone:706-570-0759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor