Provider Demographics
NPI:1639642754
Name:SMITH, JERRICA KIMBER (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JERRICA
Middle Name:KIMBER
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 LOVING LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-7931
Mailing Address - Country:US
Mailing Address - Phone:937-728-2602
Mailing Address - Fax:
Practice Address - Street 1:175 CAPE MAY DR.
Practice Address - Street 2:THERAPY SUITE
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177
Practice Address - Country:US
Practice Address - Phone:937-382-2995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08653225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant