Basic Information
Provider Information | |||||||||
NPI: | 1528383098 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITHSON | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 104 N WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | HERKIMER | ||||||||
State: | NY | ||||||||
PostalCode: | 133502028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3158666964 | ||||||||
FaxNumber: | 3155340030 | ||||||||
Practice Location | |||||||||
Address1: | 104 N WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | HERKIMER | ||||||||
State: | NY | ||||||||
PostalCode: | 133502028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3158666964 | ||||||||
FaxNumber: | 3155340030 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2010 | ||||||||
LastUpdateDate: | 06/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 032476-1 | NY | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 31124 | 05 | NY |   | MEDICAID |