Provider Demographics
NPI:1548712615
Name:SMITH, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
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 1:40 N HURRICANE HLS
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:KY
Mailing Address - Zip Code:40107-7500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 N HURRICANE HLS
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:KY
Practice Address - Zip Code:40107-7500
Practice Address - Country:US
Practice Address - Phone:502-827-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR365375225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist