Healthcare Provider Details

I. General information

NPI: 1205505666
Provider Name (Legal Business Name): JONATHAN SMITH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BROOKMAN DR EXT
BROOKHAVEN MS
39601-2371
US

IV. Provider business mailing address

427 HIGHWAY 51 N
BROOKHAVEN MS
39601-2350
US

V. Phone/Fax

Practice location:
  • Phone: 601-823-5275
  • Fax:
Mailing address:
  • Phone: 601-833-6011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904849
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: