Provider Demographics
NPI:1215416532
Name:SMITH, JOEANN JEARLENE
Entity Type:Individual
Prefix:
First Name:JOEANN
Middle Name:JEARLENE
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 1:9546 ENGLISH IVY CT
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-6962
Mailing Address - Country:US
Mailing Address - Phone:321-914-9747
Mailing Address - Fax:
Practice Address - Street 1:9546 ENGLISH IVY CT
Practice Address - Street 2:
Practice Address - City:FORTSON
Practice Address - State:GA
Practice Address - Zip Code:31808-6962
Practice Address - Country:US
Practice Address - Phone:321-914-9747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health