Healthcare Provider Details

I. General information

NPI: 1477404143
Provider Name (Legal Business Name): MR. LEROY SMITH JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2026
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4223 WILL O RUN DR
JACKSON MS
39212-3421
US

IV. Provider business mailing address

4223 WILL O RUN DR
JACKSON MS
39212-3421
US

V. Phone/Fax

Practice location:
  • Phone: 682-377-3203
  • Fax:
Mailing address:
  • Phone: 682-377-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: