Provider Demographics
NPI:1063913648
Name:SMITH, JEFFERY DAVID (OTRL)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 WOODVIEW CT APT 308
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4193
Mailing Address - Country:US
Mailing Address - Phone:734-308-3482
Mailing Address - Fax:
Practice Address - Street 1:1255 W SILVERBELL RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-1345
Practice Address - Country:US
Practice Address - Phone:248-391-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009064225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist