Provider Demographics
NPI:1164655734
Name:SMITH, JONATHAN LEE (DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2030
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:STE 1D
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3256
Practice Address - Country:US
Practice Address - Phone:423-578-1560
Practice Address - Fax:423-392-7055
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT8024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPENDINGMedicaid
TNPENDINGMedicaid
TN103I086169Medicare UPIN
TNPENDINGMedicare PIN