Provider Demographics
NPI:1417625047
Name:SMITH, PRINCETON JAKOURTNEE (PHD)
Entity Type:Individual
Prefix:
First Name:PRINCETON
Middle Name:JAKOURTNEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7593
Mailing Address - Country:US
Mailing Address - Phone:321-326-8616
Mailing Address - Fax:
Practice Address - Street 1:1200 DELTONA BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-6306
Practice Address - Country:US
Practice Address - Phone:407-716-4564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11225103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist