Provider Demographics
NPI:1487183034
Name:SMITH, JASON KYLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:KYLE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 MCGINNIS FERRY RD APT 1702
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7224
Mailing Address - Country:US
Mailing Address - Phone:704-609-6367
Mailing Address - Fax:
Practice Address - Street 1:575 PROFESSIONAL DR STE 370
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3334
Practice Address - Country:US
Practice Address - Phone:678-205-5420
Practice Address - Fax:678-205-5420
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist