MEDICARE: JENNIFER K SMITH LMT

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	2255A2300X	Athletic Trainer	2245383	AZ
2	225700000X	Massage Therapist	MT11843	SD

General Provider Information

NPI Number	:	1669138137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER K SMITH LMT

Provider Business Mailing Address
First Line	:	PO BOX 2034
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57709-2034
Country	:	US
Telephone Number	:	605-923-8621
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 W MAIN ST STE 311
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2443
Country	:	US
Telephone Number	:	605-923-8621
Fax Number	:

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

Provider Enumeration Date	:	11/09/2021
Last Update Date	:	11/09/2021

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