Basic Information
| Provider Information | |||||||||
| NPI: | 1396378543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | RBT. BBA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6201 COLLEYVILLE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLLEYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760346236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179528917 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6201 COLLEYVILLE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLLEYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760346236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179528917 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2020 | ||||||||
| LastUpdateDate: | 02/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-17-43884 | TX | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-17-43884 | 01 | TX | TRICARE | OTHER |