Provider Demographics
NPI:1053340471
Name:SMITH, JENNIFER M (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 PROFESSIONAL CT SE
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-7020
Mailing Address - Country:US
Mailing Address - Phone:706-625-5900
Mailing Address - Fax:706-625-5906
Practice Address - Street 1:204 PROFESSIONAL CT SE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-7020
Practice Address - Country:US
Practice Address - Phone:706-625-5900
Practice Address - Fax:706-625-5906
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant