Provider Demographics
NPI:1780634113
Name:SMITH, JEREMY LYNN (MA, ATC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 POWELL ST
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-4106
Mailing Address - Country:US
Mailing Address - Phone:970-858-8729
Mailing Address - Fax:
Practice Address - Street 1:2020 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2914
Practice Address - Country:US
Practice Address - Phone:970-245-0484
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2255A2300XOtherATHLETIC TRAINER