Provider Demographics
NPI:1114038536
Name:SMITH, JEFFERY TODD (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:TODD
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-1903
Mailing Address - Country:US
Mailing Address - Phone:606-340-0340
Mailing Address - Fax:606-340-0211
Practice Address - Street 1:1104 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-1903
Practice Address - Country:US
Practice Address - Phone:606-340-0340
Practice Address - Fax:606-340-0211
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4557111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85000594Medicaid