Provider Demographics
NPI:1639781412
Name:SMITH, JESSICA DIANE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:10 VILLAGE WEST DR STE A
Practice Address - Street 2:
Practice Address - City:SENOIA
Practice Address - State:GA
Practice Address - Zip Code:30276-3549
Practice Address - Country:US
Practice Address - Phone:678-723-4415
Practice Address - Fax:678-723-4416
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist