Provider Demographics
NPI:1407550668
Name:SMITH, JACQUITA DEADRA (AGNP-C)
Entity Type:Individual
Prefix:
First Name:JACQUITA
Middle Name:DEADRA
Last Name:SMITH
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 SUGARBERRY DR NE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-8069
Mailing Address - Country:US
Mailing Address - Phone:478-363-5428
Mailing Address - Fax:
Practice Address - Street 1:201 JORDAN RD STE 200
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-4495
Practice Address - Country:US
Practice Address - Phone:731-847-1428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN275254363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology