Basic Information
| Provider Information | |||||||||
| NPI: | 1861672099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3491 GANDY BLVD N STE 201 | ||||||||
| Address2: | |||||||||
| City: | PINELLAS PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337812654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277551516 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2400 S 48TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727626683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4798722441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2007 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.