Provider Demographics
NPI:1972925709
Name:SMITH, JAWAUNA (PA-C)
Entity type:Individual
Prefix:
First Name:JAWAUNA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8208 WESLEY PROVIDENCE PKWY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6966
Mailing Address - Country:US
Mailing Address - Phone:678-939-9051
Mailing Address - Fax:
Practice Address - Street 1:4343 SHALLOWFORD RD STE B4A
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5003
Practice Address - Country:US
Practice Address - Phone:770-992-0002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006455363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical