Provider Demographics
NPI:1457962904
Name:SMITH, JADIE MARIE
Entity Type:Individual
Prefix:MISS
First Name:JADIE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-2052
Mailing Address - Country:US
Mailing Address - Phone:724-349-5070
Mailing Address - Fax:724-349-8368
Practice Address - Street 1:81 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-2605
Practice Address - Country:US
Practice Address - Phone:724-349-5070
Practice Address - Fax:724-349-8368
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPSL001347235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPSL001347OtherPA PROVISIONAL LICENSE