Provider Demographics
NPI:1659450773
Name:SMITH, JACK STEVEN (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:STEVEN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:S
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1815 W MISSOURI AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3047
Mailing Address - Country:US
Mailing Address - Phone:623-398-9213
Mailing Address - Fax:
Practice Address - Street 1:1815 W MISSOURI AVE STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3047
Practice Address - Country:US
Practice Address - Phone:623-398-9213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ684111N00000X
AZ171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZDC684Medicare UPIN