Provider Demographics
NPI:1528036704
Name:SMITH, JACK BRADLEY (PA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:BRADLEY
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:4401 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1785
Practice Address - Country:US
Practice Address - Phone:405-751-4664
Practice Address - Fax:405-749-4561
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant