Provider Demographics
NPI:1376902288
Name:SMITH, JAKE WAYNE (DC, MS, BS)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC, MS, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 SHADOW POINTE DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3685
Mailing Address - Country:US
Mailing Address - Phone:314-800-8609
Mailing Address - Fax:
Practice Address - Street 1:1676 BRYAN RD STE 111
Practice Address - Street 2:
Practice Address - City:DARDENNE PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63368-4801
Practice Address - Country:US
Practice Address - Phone:314-800-8609
Practice Address - Fax:636-385-6507
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016043441111NR0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty