MEDICARE: JEAN D SMITH MA, CCC-SLP

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	235Z00000X	Speech-Language Pathologist	SP-1223	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11589618	OTHER	OH	CAQH

General Provider Information

NPI Number	:	1760414395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN D SMITH MA, CCC-SLP

Provider Business Mailing Address
First Line	:	313 LUCAS ST E
Second Line	:
City	:	CASTALIA
State	:	OH
Zip	:	44824-9782
Country	:	US
Telephone Number	:	419-901-0816
Fax Number	:

Provider Business Practice Location Address
First Line	:	313 LUCAS ST E
Second Line	:
City	:	CASTALIA
State	:	OH
Zip	:	44824-9782
Country	:	US
Telephone Number	:	419-901-0816
Fax Number	:

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	11/12/2014

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Directions to “ JEAN D SMITH MA, CCC-SLP” Practice Location

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