Provider Demographics
NPI:1225554058
Name:SMITH, JARROD
Entity Type:Individual
Prefix:
First Name:JARROD
Middle Name:
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 1:1060 GAFFNEY RD STOP 7440
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-5007
Mailing Address - Country:US
Mailing Address - Phone:907-361-5603
Mailing Address - Fax:907-361-4847
Practice Address - Street 1:1060 GAFFNEY RD STOP 7440
Practice Address - Street 2:
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-5007
Practice Address - Country:US
Practice Address - Phone:907-361-5603
Practice Address - Fax:907-361-4847
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012233A261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy