Provider Demographics
NPI:1619250495
Name:SMITH, JILLENE C
Entity Type:Individual
Prefix:
First Name:JILLENE
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 VICTOR ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2238
Mailing Address - Country:US
Mailing Address - Phone:360-920-3373
Mailing Address - Fax:
Practice Address - Street 1:2415 VICTOR ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2238
Practice Address - Country:US
Practice Address - Phone:360-920-3373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000086072251P0200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic