Provider Demographics
NPI:1003517129
Name:SMITH, JASON LAMAR
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LAMAR
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1734
Mailing Address - Country:US
Mailing Address - Phone:937-856-5153
Mailing Address - Fax:
Practice Address - Street 1:750 S 3RD ST
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-1734
Practice Address - Country:US
Practice Address - Phone:937-856-5153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker