Provider Demographics
NPI:1750991071
Name:SMITH, JADE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 E BETHANY HOME RD APT 33A
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2043
Mailing Address - Country:US
Mailing Address - Phone:505-290-3917
Mailing Address - Fax:
Practice Address - Street 1:1244 E BETHANY HOME RD APT 33A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2043
Practice Address - Country:US
Practice Address - Phone:505-290-3917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-01
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008482225X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program