Provider Demographics
NPI:1023408291
Name:SMITH, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MOSELEY RD
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-7148
Mailing Address - Country:US
Mailing Address - Phone:478-654-5327
Mailing Address - Fax:478-654-5218
Practice Address - Street 1:103 MOSELEY RD
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008-7148
Practice Address - Country:US
Practice Address - Phone:478-654-5327
Practice Address - Fax:478-654-5218
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN157256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily