Provider Demographics
NPI:1164981163
Name:SMITH, JEFFREY M (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
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 1:4048 CEDAR BLUFF DR STE 2
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8895
Mailing Address - Country:US
Mailing Address - Phone:231-347-5120
Mailing Address - Fax:231-347-4844
Practice Address - Street 1:4048 CEDAR BLUFF DR STE 2
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8895
Practice Address - Country:US
Practice Address - Phone:231-347-5120
Practice Address - Fax:231-347-4844
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist