Provider Demographics
NPI:1225774102
Name:SMITH, JIMMY B
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:B
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 1:143 RECKART LN
Mailing Address - Street 2:
Mailing Address - City:TERRA ALTA
Mailing Address - State:WV
Mailing Address - Zip Code:26764-8065
Mailing Address - Country:US
Mailing Address - Phone:304-291-9066
Mailing Address - Fax:
Practice Address - Street 1:143 RECKART LN
Practice Address - Street 2:
Practice Address - City:TERRA ALTA
Practice Address - State:WV
Practice Address - Zip Code:26764-8065
Practice Address - Country:US
Practice Address - Phone:304-291-9066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant