Healthcare Provider Details

I. General information

NPI: 1427300433
Provider Name (Legal Business Name): JESSICA RAE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1685 SOUTH 21ST STREET
COLORADO SPRINGS CO
80904-5123
US

IV. Provider business mailing address

1685 SOUTH 21ST STREET
COLORADO SPRINGS CO
80904-5123
US

V. Phone/Fax

Practice location:
  • Phone: 719-329-1774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.0012947
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0828
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: