Provider Demographics
NPI:1174162804
Name:SMITH, JAIMIE (MSOTR/L)
Entity type:Individual
Prefix:
First Name:JAIMIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 CHESTNUT DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-5639
Mailing Address - Country:US
Mailing Address - Phone:973-800-5743
Mailing Address - Fax:
Practice Address - Street 1:1818 AVENUE P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1304
Practice Address - Country:US
Practice Address - Phone:718-677-0797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-28
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ899600225X00000X
NY0223111225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist