Healthcare Provider Details

I. General information

NPI: 1205005071
Provider Name (Legal Business Name): BRIENNE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 N FLAG CHAPEL RD
JACKSON MS
39209-2206
US

IV. Provider business mailing address

733 N FLAG CHAPEL RD
JACKSON MS
39209-2206
US

V. Phone/Fax

Practice location:
  • Phone: 601-922-5530
  • Fax:
Mailing address:
  • Phone: 601-922-5530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA2942
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: