Provider Demographics
NPI:1821789538
Name:SMITH, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 S FULTON AVE UNIT 1504
Mailing Address - Street 2:
Mailing Address - City:HAPEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30354-1773
Mailing Address - Country:US
Mailing Address - Phone:706-619-4337
Mailing Address - Fax:
Practice Address - Street 1:2700 PATRICK HENRY PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9108
Practice Address - Country:US
Practice Address - Phone:770-464-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP011716235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist