Provider Demographics
NPI:1649571027
Name:SMITH, LEJUAHN
Entity Type:Individual
Prefix:
First Name:LEJUAHN
Middle Name:
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 1:1321 N BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-4951
Mailing Address - Country:US
Mailing Address - Phone:405-216-5252
Mailing Address - Fax:405-216-5353
Practice Address - Street 1:1321 N BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-4951
Practice Address - Country:US
Practice Address - Phone:405-216-5252
Practice Address - Fax:405-216-5353
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOCC-14771225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist