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General NPI Number Information
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NPI Number | 1982283263
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Entity Type | Individual
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Provider Name | JEASICA NICOLE SMITH
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Gender | Female
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Dates
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Enumeration Date | 04/05/2021
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Last Update Date | 04/05/2021
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Provider Practice Location Address
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Address Line | 11 PALM AVE
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City | YUKON
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State | OK
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Zip | 73099-5645
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Country | US
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Telephone | 405-312-4630
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Fax |
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Provider Business Mailing Address
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Address Line | 2600 COMPASS RD
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City | GLENVIEW
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State | IL
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Zip | 60026-8001
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 841
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License Number State | OK
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