Provider Demographics
NPI:1952593691
Name:SMITH, JACK W (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3556 EARLY WOODLAND PL
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4732
Mailing Address - Country:US
Mailing Address - Phone:703-425-7764
Mailing Address - Fax:
Practice Address - Street 1:5111 LEESBURG PIKE
Practice Address - Street 2:SKYLINE 5, SUITE 601
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22041-3251
Practice Address - Country:US
Practice Address - Phone:703-681-1708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033705207Q00000X
FLME 51346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine