Provider Demographics
NPI:1790344265
Name:SMITH, JIMMY DALE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 CHISHOLM TRL
Mailing Address - Street 2:
Mailing Address - City:KRUM
Mailing Address - State:TX
Mailing Address - Zip Code:76249-7178
Mailing Address - Country:US
Mailing Address - Phone:940-736-1815
Mailing Address - Fax:
Practice Address - Street 1:11751 ALTA VISTA RD STE 301
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6443
Practice Address - Country:US
Practice Address - Phone:817-337-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31241382251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic