Provider Demographics
NPI:1164571451
Name:SMITH, JIMMY J (DC)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:J
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 1:551 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TRAER
Mailing Address - State:IA
Mailing Address - Zip Code:50675-1138
Mailing Address - Country:US
Mailing Address - Phone:319-478-8515
Mailing Address - Fax:319-478-8497
Practice Address - Street 1:551 2ND ST
Practice Address - Street 2:
Practice Address - City:TRAER
Practice Address - State:IA
Practice Address - Zip Code:50675-1138
Practice Address - Country:US
Practice Address - Phone:319-478-8515
Practice Address - Fax:319-478-8497
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA5449111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA70908OtherWELLMARK BCBS
IA0070748Medicaid
IA1164571451Medicaid
IA252196OtherMIDLANDS CHOICE
IA02918OtherWELLMARK BC BS
IAT87205Medicare UPIN
IA70908OtherWELLMARK BCBS
IA0070748Medicaid