Provider Demographics
NPI:1346204344
Name:SMITH, JENNIFER A (MSPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2120 43RD ST SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-3772
Mailing Address - Country:US
Mailing Address - Phone:616-281-1144
Mailing Address - Fax:
Practice Address - Street 1:1535 44TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-4313
Practice Address - Country:US
Practice Address - Phone:616-281-1144
Practice Address - Fax:616-530-2140
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010833225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist