Basic Information
| Provider Information | |||||||||
| NPI: | 1689083354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MHS/PA-C;MS/CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506063 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 4451 BAYOU BLVD | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504167619 | ||||||||
| FaxNumber: | 8504167753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2014 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA12713 | FL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 3571 | AL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 363A00000X | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA9112483 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.