Provider Demographics
NPI:1538572730
Name:SMITH, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-8140
Mailing Address - Country:US
Mailing Address - Phone:706-867-0106
Mailing Address - Fax:706-864-3368
Practice Address - Street 1:50 TANGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-8140
Practice Address - Country:US
Practice Address - Phone:706-867-0106
Practice Address - Fax:706-864-3368
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH005362310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility