Provider Demographics
NPI:1477332633
Name:SMITH, JEFF THOMAS
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:THOMAS
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 1:20 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43912-1411
Mailing Address - Country:US
Mailing Address - Phone:304-650-1767
Mailing Address - Fax:
Practice Address - Street 1:20 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912-1411
Practice Address - Country:US
Practice Address - Phone:304-650-1767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821206228Medicaid
WV125553494Medicaid
WV1356607394Medicaid