Provider Demographics
NPI:1598367682
Name:SMITH, JORDAN MACKENZIE (PA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MACKENZIE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:OH
Mailing Address - Zip Code:45215-3226
Mailing Address - Country:US
Mailing Address - Phone:513-502-5833
Mailing Address - Fax:
Practice Address - Street 1:262 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:OH
Practice Address - Zip Code:45050-1236
Practice Address - Country:US
Practice Address - Phone:513-461-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363A00000X
OH50.006767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant