Provider Demographics
NPI:1457857765
Name:SMITH, JASON WAYNE (NP)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 COLLEGE PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-0600
Mailing Address - Country:US
Mailing Address - Phone:706-965-4060
Mailing Address - Fax:706-965-4080
Practice Address - Street 1:45 COLLEGE PARK DR STE A
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-0600
Practice Address - Country:US
Practice Address - Phone:706-965-4060
Practice Address - Fax:706-965-4080
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213331363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003205193BMedicaid