Healthcare Provider Details

I. General information

NPI: 1447415575
Provider Name (Legal Business Name): MRS. JESSIE C SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 PRIMACY PKWY
MEMPHIS TN
38119-5763
US

IV. Provider business mailing address

5483 LA STRADA STREET
MEMPHIS TN
38116
US

V. Phone/Fax

Practice location:
  • Phone: 901-767-1040
  • Fax:
Mailing address:
  • Phone: 901-345-8556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA266
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: