Provider Demographics
NPI:1205505666
Name:SMITH, JONATHAN (FNP)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2350
Mailing Address - Country:US
Mailing Address - Phone:601-833-6011
Mailing Address - Fax:
Practice Address - Street 1:601 BROOKMAN DR EXT
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2371
Practice Address - Country:US
Practice Address - Phone:601-823-5275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904849363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty