Healthcare Provider Details

I. General information

NPI: 1689083354
Provider Name (Legal Business Name): JOSEPH B. SMITH JR. MHS/PA-C;MS/CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4451 BAYOU BLVD
PENSACOLA FL
32503-2601
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-7619
  • Fax: 850-416-7753
Mailing address:
  • Phone: 904-450-6063
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA12713
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3571
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112483
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: