Provider Demographics
NPI:1447723101
Name:SMITH, JEFFREY CLINTON
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CLINTON
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 W PALMER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-2877
Mailing Address - Country:US
Mailing Address - Phone:719-287-1630
Mailing Address - Fax:
Practice Address - Street 1:254 W PALMER LAKE DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-2877
Practice Address - Country:US
Practice Address - Phone:719-287-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-05
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0018492225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist