Provider Demographics
NPI:1447536883
Name:SMITH, JASON MATTHEW (PTA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:SMITH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40239 CATANIA CT
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92203-3814
Mailing Address - Country:US
Mailing Address - Phone:714-470-8146
Mailing Address - Fax:
Practice Address - Street 1:47647 CALEO BAY DR STE 130
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-8857
Practice Address - Country:US
Practice Address - Phone:760-771-9054
Practice Address - Fax:760-771-9057
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT9432225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant