Healthcare Provider Details

I. General information

NPI: 1801453618
Provider Name (Legal Business Name): JESSICA ASHLEY SMITH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 AYERS CIR
LULA GA
30554-3341
US

IV. Provider business mailing address

244 AYERS CIR
LULA GA
30554-3341
US

V. Phone/Fax

Practice location:
  • Phone: 706-371-5414
  • Fax:
Mailing address:
  • Phone: 706-371-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number215972
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: