Provider Demographics
NPI:1255190682
Name:SIMONDS, JACKIE GRANT (DO)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:GRANT
Last Name:SIMONDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4621 WINDCROFT CIR
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-3484
Mailing Address - Country:US
Mailing Address - Phone:770-875-5187
Mailing Address - Fax:309-326-4515
Practice Address - Street 1:201 14TH ST SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3133
Practice Address - Country:US
Practice Address - Phone:727-588-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program