Healthcare Provider Details

I. General information

NPI: 1861169211
Provider Name (Legal Business Name): JENNIFER LYNN SMITH NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 WINDERMERE PKWY STE 105
CUMMING GA
30041-7033
US

IV. Provider business mailing address

3850 WINDERMERE PKWY STE 105
CUMMING GA
30041-7033
US

V. Phone/Fax

Practice location:
  • Phone: 678-455-2800
  • Fax:
Mailing address:
  • Phone: 678-455-2800
  • Fax: 770-888-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number268863
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN268863
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN268863
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: