Provider Demographics
NPI:1154587558
Name:SMITH, JONATHAN MICHAEL (LMT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2327
Mailing Address - Country:US
Mailing Address - Phone:518-755-7759
Mailing Address - Fax:
Practice Address - Street 1:142 GREEN ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2327
Practice Address - Country:US
Practice Address - Phone:518-755-7759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013939-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist