Provider Demographics
NPI:1639781412
Name:SMITH, JESSICA DIANE (PT, DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
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 1:680 S 9TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4216
Mailing Address - Country:US
Mailing Address - Phone:770-229-6141
Mailing Address - Fax:770-229-6142
Practice Address - Street 1:680 S 9TH ST STE A
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4216
Practice Address - Country:US
Practice Address - Phone:770-229-6141
Practice Address - Fax:770-229-6142
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist