Provider Demographics
NPI:1053470534
Name:SMITH, JEFFRERY SCOTT (PT)
Entity Type:Individual
Prefix:
First Name:JEFFRERY
Middle Name:SCOTT
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 CORTE GRANADA
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-7877
Mailing Address - Country:US
Mailing Address - Phone:707-410-9857
Mailing Address - Fax:
Practice Address - Street 1:222 ACACIA ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3800
Practice Address - Country:US
Practice Address - Phone:707-421-2095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 16012225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0097610Medicaid
CAP30869Medicare UPIN
CAPT0097610Medicaid