Healthcare Provider Details

I. General information

NPI: 1497382915
Provider Name (Legal Business Name): JEREMY SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 OSTRUM ST
BETHLEHEM PA
18015-1000
US

IV. Provider business mailing address

29 S GREEN ST # B
EAST STROUDSBURG PA
18301-2607
US

V. Phone/Fax

Practice location:
  • Phone: 866-785-8537
  • Fax:
Mailing address:
  • Phone: 484-523-4316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRTO000519
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: