Healthcare Provider Details

I. General information

NPI: 1174633713
Provider Name (Legal Business Name): JASON SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18561 N 59TH AVE STE 117
GLENDALE AZ
85308-1256
US

IV. Provider business mailing address

15681 N 29TH ST
PHOENIX AZ
85032-3726
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-0654
  • Fax: 623-322-0664
Mailing address:
  • Phone: 602-932-2159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6742
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: