Healthcare Provider Details

I. General information

NPI: 1104737758
Provider Name (Legal Business Name): JEREMIAH SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 B ST APT 1
LITTLE ROCK AR
72205-3372
US

IV. Provider business mailing address

5700 B ST APT 1
LITTLE ROCK AR
72205-3372
US

V. Phone/Fax

Practice location:
  • Phone: 501-944-3131
  • Fax:
Mailing address:
  • Phone: 501-944-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPI23763
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: