Provider Demographics
NPI:1740280825
Name:SMITH, JERRY DEAN (DC)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 E TENNESSEE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-7640
Mailing Address - Country:US
Mailing Address - Phone:850-222-5700
Mailing Address - Fax:850-222-8585
Practice Address - Street 1:487 E TENNESSEE ST STE 3
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-7640
Practice Address - Country:US
Practice Address - Phone:850-222-5700
Practice Address - Fax:850-222-8585
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3455111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T74525Medicare UPIN