Basic Information
Provider Information
NPI: 1003140088
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: JENNIFER
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 889 BROADWAY # 4F
Address2:  
City: BROOKLYN
State: NY
PostalCode: 112065996
CountryCode: US
TelephoneNumber: 9177040608
FaxNumber:  
Practice Location
Address1: 64 DANBURY RD
Address2:  
City: WILTON
State: CT
PostalCode: 068974429
CountryCode: US
TelephoneNumber: 8002780332
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/24/2009
LastUpdateDate: 02/14/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X030246NYY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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