Provider Demographics
NPI:1386405868
Name:SMITH, KEIANNA SHANIQUA
Entity type:Individual
Prefix:
First Name:KEIANNA
Middle Name:SHANIQUA
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 1:6339 ARGYLE FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-6666
Mailing Address - Country:US
Mailing Address - Phone:904-613-5005
Mailing Address - Fax:
Practice Address - Street 1:6339 ARGYLE FOREST BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-6666
Practice Address - Country:US
Practice Address - Phone:904-613-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician