Healthcare Provider Details

I. General information

NPI: 1922945229
Provider Name (Legal Business Name): JACOB BASTON SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 DIXIE ST
CARROLLTON GA
30117-3818
US

IV. Provider business mailing address

607 VALLEY RUN DR
BREMEN GA
30110-2413
US

V. Phone/Fax

Practice location:
  • Phone: 770-836-9597
  • Fax:
Mailing address:
  • Phone: 678-836-3697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: