Healthcare Provider Details

I. General information

NPI: 1386833648
Provider Name (Legal Business Name): JEAN MARIE SMITH P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 W CENTRE AVE
PORTAGE MI
49024-5351
US

IV. Provider business mailing address

343 SHANGRI LA CIR
PLAINWELL MI
49080-9105
US

V. Phone/Fax

Practice location:
  • Phone: 269-323-4449
  • Fax:
Mailing address:
  • Phone: 269-650-4454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number001802
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: