Provider Demographics
NPI:1528383098
Name:SMITHSON, JESSICA (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SMITHSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-2028
Mailing Address - Country:US
Mailing Address - Phone:315-866-6964
Mailing Address - Fax:315-534-0030
Practice Address - Street 1:104 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-2028
Practice Address - Country:US
Practice Address - Phone:315-866-6964
Practice Address - Fax:315-534-0030
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032476-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY31124Medicaid