Provider Demographics
NPI:1740645431
Name:SMITH, JERIKKA
Entity type:Individual
Prefix:
First Name:JERIKKA
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 1:1311 BARBERRY LN
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-6915
Mailing Address - Country:US
Mailing Address - Phone:706-313-4734
Mailing Address - Fax:
Practice Address - Street 1:560 GRADY AVE STE C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1975
Practice Address - Country:US
Practice Address - Phone:770-461-6488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist