Provider Demographics
NPI:1558431338
Name:SMITH, JAYSON PHILLIPS (PT)
Entity Type:Individual
Prefix:DR
First Name:JAYSON
Middle Name:PHILLIPS
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2822 PINNACLE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6324
Mailing Address - Country:US
Mailing Address - Phone:334-233-4960
Mailing Address - Fax:662-624-4876
Practice Address - Street 1:1015 LEE DR
Practice Address - Street 2:SUITE 1 B
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-3698
Practice Address - Country:US
Practice Address - Phone:662-624-2466
Practice Address - Fax:662-624-4876
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist