Provider Demographics
NPI:1205809423
Name:SMART, JENNIFER H (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:H
Last Name:SMART
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 894
Mailing Address - Street 2:
Mailing Address - City:ORIENTAL
Mailing Address - State:NC
Mailing Address - Zip Code:28571-0769
Mailing Address - Country:US
Mailing Address - Phone:252-249-1869
Mailing Address - Fax:252-249-0112
Practice Address - Street 1:1006 BROAD STREET
Practice Address - Street 2:
Practice Address - City:ORIENTAL
Practice Address - State:NC
Practice Address - Zip Code:28571-0769
Practice Address - Country:US
Practice Address - Phone:252-249-1869
Practice Address - Fax:252-249-0112
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4279174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC078AZOtherBCBS
NC7211378Medicaid
NC2504038Medicare ID - Type Unspecified