Provider Demographics
NPI:1184459513
Name:SMITH, JEFFREY DEAN (PTA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 EVERGREEN
Mailing Address - Street 2:
Mailing Address - City:WATHENA
Mailing Address - State:KS
Mailing Address - Zip Code:66090-1206
Mailing Address - Country:US
Mailing Address - Phone:816-261-7578
Mailing Address - Fax:
Practice Address - Street 1:2800 TOWLE ST
Practice Address - Street 2:
Practice Address - City:FALLS CITY
Practice Address - State:NE
Practice Address - Zip Code:68355-1065
Practice Address - Country:US
Practice Address - Phone:402-245-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018032905225200000X
KS14-03420225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant