Healthcare Provider Details

I. General information

NPI: 1073436200
Provider Name (Legal Business Name): JASON MATTHEW SMITH MS, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 SMITH FIELDHOUSE
PROVO UT
84602-2246
US

IV. Provider business mailing address

688 W 800 N
PROVO UT
84601-1517
US

V. Phone/Fax

Practice location:
  • Phone: 801-422-2946
  • Fax:
Mailing address:
  • Phone: 956-222-6872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT2562
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: