Healthcare Provider Details

I. General information

NPI: 1710697115
Provider Name (Legal Business Name): JEFFREY DON SMITH APRN, AGCNS-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

IV. Provider business mailing address

2854 LAKE VISTA RD
JACKSONVILLE FL
32223-7934
US

V. Phone/Fax

Practice location:
  • Phone: 904-956-0097
  • Fax:
Mailing address:
  • Phone: 904-631-8875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number11021773
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: