Provider Demographics
NPI:1609018068
Name:SMITH, JENNIFER W (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:W
Last Name:SMITH
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:900 CIRCLE 75 PKWY SE
Mailing Address - Street 2:SUITE 1700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3035
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:770-953-6972
Practice Address - Street 1:771 OLD NORCROSS RD
Practice Address - Street 2:SUITES 155 AND 390
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4386
Practice Address - Country:US
Practice Address - Phone:770-682-6000
Practice Address - Fax:770-513-1103
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2015-09-01
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Provider Licenses
StateLicense IDTaxonomies
GA007248363A00000X
NC0010-01784363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2760018Medicare PIN