Healthcare Provider Details

I. General information

NPI: 1952387565
Provider Name (Legal Business Name): JENNIFER J. SMITH M.S., A.T.,C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 E STEPHENS ST MIDWAY COLLEGE
MIDWAY KY
40347-1112
US

IV. Provider business mailing address

159 BERKSHIRE LN
GEORGETOWN KY
40324-8818
US

V. Phone/Fax

Practice location:
  • Phone: 859-846-5806
  • Fax:
Mailing address:
  • Phone: 574-527-8667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT601
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: