Provider Demographics
NPI:1033487855
Name:SMITH, JESSICA ELAINE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4242 RIVERSIDE PARK RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-2872
Mailing Address - Country:US
Mailing Address - Phone:407-399-9478
Mailing Address - Fax:407-362-9889
Practice Address - Street 1:4242 RIVERSIDE PARK RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-2872
Practice Address - Country:US
Practice Address - Phone:407-399-9478
Practice Address - Fax:407-362-9889
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 17343225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist