Provider Demographics
NPI:1437388477
Name:SMITH, JENNIFER NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7440 REBECCA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:45369-9737
Mailing Address - Country:US
Mailing Address - Phone:937-346-6073
Mailing Address - Fax:
Practice Address - Street 1:2665 DERR RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2445
Practice Address - Country:US
Practice Address - Phone:937-390-6138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.017732225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist