Healthcare Provider Details

I. General information

NPI: 1154999530
Provider Name (Legal Business Name): JACOB SMITH LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date: 10/26/2022
Reactivation Date: 11/01/2022

III. Provider practice location address

9249 HIGHWAY 29 S
ATHENS GA
30601-6352
US

IV. Provider business mailing address

9249 HIGHWAY 29 S
ATHENS GA
30601-6352
US

V. Phone/Fax

Practice location:
  • Phone: 706-227-4534
  • Fax:
Mailing address:
  • Phone: 706-733-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW008283
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: