Provider Demographics
NPI:1891737854
Name:SMITH, JACQUELINE T (DPM)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:T
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 SPARTA ST
Mailing Address - Street 2:
Mailing Address - City:MC MINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1317
Mailing Address - Country:US
Mailing Address - Phone:931-473-9528
Mailing Address - Fax:931-473-1618
Practice Address - Street 1:1502 SPARTA ST
Practice Address - Street 2:
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1317
Practice Address - Country:US
Practice Address - Phone:931-473-9528
Practice Address - Fax:931-473-1618
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN262213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3351150Medicaid
TN3351150Medicare PIN
TN3351150Medicaid
TNT61094Medicare UPIN