Basic Information
Provider Information | |||||||||
NPI: | 1871509331 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OTT | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2230 SW 19TH AVENUE RD | ||||||||
Address2: |   | ||||||||
City: | OCALA | ||||||||
State: | FL | ||||||||
PostalCode: | 344711391 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3522374133 | ||||||||
FaxNumber: | 3522377728 | ||||||||
Practice Location | |||||||||
Address1: | 2131 SW 20TH PL | ||||||||
Address2: |   | ||||||||
City: | OCALA | ||||||||
State: | FL | ||||||||
PostalCode: | 344717734 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3522374133 | ||||||||
FaxNumber: | 3522377728 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2006 | ||||||||
LastUpdateDate: | 04/02/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT30132 | FL | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 7211861 | 05 | NC |   | MEDICAID | D3037 | 01 | NC | MEDCOST NC | OTHER | 079A6 | 01 | NC | BCBS NC | OTHER |