Provider Demographics
NPI:1588540785
Name:SMITH, KENLEE JO (PTA)
Entity type:Individual
Prefix:
First Name:KENLEE
Middle Name:JO
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7602
Mailing Address - Country:US
Mailing Address - Phone:918-504-8669
Mailing Address - Fax:918-512-4773
Practice Address - Street 1:117 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7602
Practice Address - Country:US
Practice Address - Phone:918-504-8669
Practice Address - Fax:918-512-4773
Is Sole Proprietor?:No
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3924225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant