Provider Demographics
NPI:1154999530
Name:SMITH, JACOB (LMSW)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9249 HIGHWAY 29 S
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-6352
Mailing Address - Country:US
Mailing Address - Phone:706-733-0188
Mailing Address - Fax:
Practice Address - Street 1:9249 HIGHWAY 29 S
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-6352
Practice Address - Country:US
Practice Address - Phone:706-227-4534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2022-11-01
Deactivation Date:2022-10-26
Deactivation Code:
Reactivation Date:2022-11-01
Provider Licenses
StateLicense IDTaxonomies
GAMSW008283104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker