Provider Demographics
NPI:1376693424
Name:SMITH, JEDIDIAH T (DC)
Entity Type:Individual
Prefix:DR
First Name:JEDIDIAH
Middle Name:T
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 PALMA DR STE 104
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5796
Mailing Address - Country:US
Mailing Address - Phone:805-642-6565
Mailing Address - Fax:
Practice Address - Street 1:1732 PALMA DR STE 104
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5796
Practice Address - Country:US
Practice Address - Phone:805-642-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK425111N00000X
CADC-30972111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCH7531Medicaid
AKCH7531Medicaid
AK160492Medicare ID - Type Unspecified