Provider Demographics
NPI:1063087989
Name:SMITH, JATARRA
Entity type:Individual
Prefix:
First Name:JATARRA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DALTON CT
Mailing Address - Street 2:
Mailing Address - City:SATSUMA
Mailing Address - State:FL
Mailing Address - Zip Code:32189-2400
Mailing Address - Country:US
Mailing Address - Phone:904-258-4645
Mailing Address - Fax:
Practice Address - Street 1:100 DALTON CT
Practice Address - Street 2:
Practice Address - City:SATSUMA
Practice Address - State:FL
Practice Address - Zip Code:32189-2400
Practice Address - Country:US
Practice Address - Phone:904-258-4645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL253Z00000X
FL237001172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL237001OtherHOMEMAKER COMPANION