Provider Demographics
NPI:1265778617
Name:SMITH, JEANIE LOU (COTA)
Entity type:Individual
Prefix:MRS
First Name:JEANIE
Middle Name:LOU
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 BERRY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-6080
Mailing Address - Country:US
Mailing Address - Phone:681-945-5078
Mailing Address - Fax:
Practice Address - Street 1:302 CEDER RIDGE RD.
Practice Address - Street 2:
Practice Address - City:SISSONVILLE
Practice Address - State:WV
Practice Address - Zip Code:25320
Practice Address - Country:US
Practice Address - Phone:304-984-0046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1879224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant