Provider Demographics
NPI:1902556848
Name:SMITH, DANIEL JACKSON (PHD, AGPCNP-BC, CNE)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JACKSON
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD, AGPCNP-BC, CNE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2913-15 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2913-15 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-3016
Practice Address - Country:US
Practice Address - Phone:609-505-9287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN280809363L00000X, 163W00000X
PARN749716163W00000X
PASP025728363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse