MEDICARE: JEREMY TYRELL SMITH

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	225700000X	Massage Therapist	LA8462	LA

General Provider Information

NPI Number	:	1871475392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY TYRELL SMITH

Provider Business Mailing Address
First Line	:	2948 MILAM ST
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-2115
Country	:	US
Telephone Number	:	225-210-0640
Fax Number	:

Provider Business Practice Location Address
First Line	:	7840 JEWELLA AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71108-5004
Country	:	US
Telephone Number	:	318-687-0881
Fax Number	:

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

Provider Enumeration Date	:	07/24/2025
Last Update Date	:	07/24/2025

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