Provider Demographics
NPI:1194370239
Name:SMITH, JEFFREY ROBERT
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CORDAGE PARK CIRCLE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-7331
Mailing Address - Country:US
Mailing Address - Phone:508-830-3444
Mailing Address - Fax:
Practice Address - Street 1:36 CORDAGE PARK CIRCLE
Practice Address - Street 2:SUITE 305
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-7331
Practice Address - Country:US
Practice Address - Phone:508-830-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker