Provider Demographics
NPI:1194035808
Name:SMITH, JILL (CPED)
Entity Type:Individual
Prefix:MISS
First Name:JILL
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 EAST BLVD
Mailing Address - Street 2:SUITE K
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5876
Mailing Address - Country:US
Mailing Address - Phone:704-335-4070
Mailing Address - Fax:
Practice Address - Street 1:1235 EAST BLVD
Practice Address - Street 2:SUITE K
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203
Practice Address - Country:US
Practice Address - Phone:704-335-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCPED3467174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist