MEDICARE: JACK BRADLEY SMITH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	1155	OK

General Provider Information

NPI Number	:	1528036704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK BRADLEY SMITH PA

Provider Business Mailing Address
First Line	:	18432 WILD HORSE TRL
Second Line	:
City	:	NORMAN
State	:	OK
Zip	:	73072-9603
Country	:	US
Telephone Number	:	405-760-0560
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 W MEMORIAL RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-1785
Country	:	US
Telephone Number	:	405-751-4664
Fax Number	:	405-749-4561

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	12/01/2025

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