Provider Demographics
NPI:1053430298
Name:SMITH, JODY A (BA)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 SW ACADEMY ST STE 304
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1900
Mailing Address - Country:US
Mailing Address - Phone:503-623-1886
Mailing Address - Fax:503-623-7560
Practice Address - Street 1:182 SW ACADEMY ST STE 304
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1900
Practice Address - Country:US
Practice Address - Phone:503-623-1886
Practice Address - Fax:503-623-7560
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator