Provider Demographics
NPI:1396267902
Name:JESSICA SMITH-BLOCKLEY, LLC
Entity type:Organization
Organization Name:JESSICA SMITH-BLOCKLEY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH-BLOCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-484-3819
Mailing Address - Street 1:131 NW HAWTHORNE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2957
Mailing Address - Country:US
Mailing Address - Phone:458-206-0862
Mailing Address - Fax:541-241-7576
Practice Address - Street 1:131 NW HAWTHORNE AVE STE 103
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2957
Practice Address - Country:US
Practice Address - Phone:458-206-0862
Practice Address - Fax:541-241-7576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR9183085OtherDRIVERS LICENSE