Provider Demographics
NPI:1649898792
Name:SMITH, JIMMIE LEE
Entity type:Individual
Prefix:
First Name:JIMMIE
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19874 N WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:NEW CANEY
Mailing Address - State:TX
Mailing Address - Zip Code:77357-6922
Mailing Address - Country:US
Mailing Address - Phone:281-399-7654
Mailing Address - Fax:936-261-7487
Practice Address - Street 1:19874 N WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:NEW CANEY
Practice Address - State:TX
Practice Address - Zip Code:77357-6922
Practice Address - Country:US
Practice Address - Phone:281-399-7654
Practice Address - Fax:936-261-7487
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX144732310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility