MEDICARE: JESSE EDWARD SMITH 373H0000X

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	373H00000X	Day Training/Habilitation Specialist

General Provider Information

NPI Number	:	1538849211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE EDWARD SMITH 373H0000X

Provider Business Mailing Address
First Line	:	1141 CHELSEA ST
Second Line	:
City	:	RIDGECREST
State	:	CA
Zip	:	93555-3208
Country	:	US
Telephone Number	:	760-463-2880
Fax Number	:	760-446-0298

Provider Business Practice Location Address
First Line	:	1141 CHELSEA ST
Second Line	:
City	:	RIDGECREST
State	:	CA
Zip	:	93555-3208
Country	:	US
Telephone Number	:	760-463-2880
Fax Number	:	760-446-0298

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

Provider Enumeration Date	:	07/19/2023
Last Update Date	:	06/28/2026

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