Provider Demographics
NPI:1760110399
Name:SMITH, JEFFREY LEE
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BETTIE ST
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045-1108
Mailing Address - Country:US
Mailing Address - Phone:681-358-0139
Mailing Address - Fax:
Practice Address - Street 1:21 BETTIE ST
Practice Address - Street 2:
Practice Address - City:CLENDENIN
Practice Address - State:WV
Practice Address - Zip Code:25045-1108
Practice Address - Country:US
Practice Address - Phone:681-358-0139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant