Provider Demographics
NPI:1710008172
Name:SMITH, MARY JACKSON (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JACKSON
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8315 FORGE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-3127
Mailing Address - Country:US
Mailing Address - Phone:804-266-8939
Mailing Address - Fax:804-266-8939
Practice Address - Street 1:13700 N GAYTON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-7017
Practice Address - Country:US
Practice Address - Phone:804-364-6352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119000372225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist