Provider Demographics
NPI:1861179822
Name:SMITH, JONATHAN EDWARD
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWARD
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 1:1014 EVERGLADE DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3515
Mailing Address - Country:US
Mailing Address - Phone:185-036-8414
Mailing Address - Fax:
Practice Address - Street 1:721 ASHLEY DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-9231
Practice Address - Country:US
Practice Address - Phone:850-752-0448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH22861101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health