Provider Demographics
NPI:1710501192
Name:SMITH, JEROME BRENT (PT)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:BRENT
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6621 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2358
Mailing Address - Country:US
Mailing Address - Phone:328-241-0008
Mailing Address - Fax:
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2358
Practice Address - Country:US
Practice Address - Phone:328-241-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039209-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist