Healthcare Provider Details

I. General information

NPI: 1700422011
Provider Name (Legal Business Name): JESSICA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 E ELM ST
ATHENS AL
35611-5318
US

IV. Provider business mailing address

1316 SOMERVILLE RD SE STE 1
DECATUR AL
35601-4309
US

V. Phone/Fax

Practice location:
  • Phone: 256-232-3661
  • Fax: 256-355-6092
Mailing address:
  • Phone: 256-260-7361
  • Fax: 256-355-6092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: