Provider Demographics
NPI:1861472193
Name:SMITH, MARIANNE JACKSON (CPHT, ATS, CRTS)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:JACKSON
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPHT, ATS, CRTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-0099
Mailing Address - Country:US
Mailing Address - Phone:706-778-7369
Mailing Address - Fax:706-776-2502
Practice Address - Street 1:639 IRVIN ST
Practice Address - Street 2:
Practice Address - City:CORNELIA
Practice Address - State:GA
Practice Address - Zip Code:30531-3267
Practice Address - Country:US
Practice Address - Phone:706-778-4918
Practice Address - Fax:706-776-2502
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
150101586580537183700000X
1002338225CA2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183700000XPharmacy Service ProvidersPharmacy Technician
Not Answered225CA2500XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Supplier