Healthcare Provider Details

I. General information

NPI: 1194653642
Provider Name (Legal Business Name): JAMAL COLIN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2712 KEITH ST
TEMPLE HILLS MD
20748-1634
US

IV. Provider business mailing address

2712 KEITH ST
TEMPLE HILLS MD
20748-1634
US

V. Phone/Fax

Practice location:
  • Phone: 917-405-9464
  • Fax:
Mailing address:
  • Phone: 917-405-9464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT210002558
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: