Provider Demographics
NPI:1710940846
Name:SMITH, JON DAVID (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 LANE 200 LAKE JAMES
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-7506
Mailing Address - Country:US
Mailing Address - Phone:260-833-9316
Mailing Address - Fax:260-665-4839
Practice Address - Street 1:1 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-1764
Practice Address - Country:US
Practice Address - Phone:260-665-4846
Practice Address - Fax:260-665-4839
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000440A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer