Healthcare Provider Details

I. General information

NPI: 1104732106
Provider Name (Legal Business Name): NICOLE DIANNA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10486 SILVERBROOK TRL
JACKSONVILLE FL
32256-5865
US

IV. Provider business mailing address

10486 SILVERBROOK TRL
JACKSONVILLE FL
32256-5865
US

V. Phone/Fax

Practice location:
  • Phone: 904-208-8014
  • Fax:
Mailing address:
  • Phone: 904-208-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS1799
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: