Provider Demographics
NPI:1295259000
Name:SMIDT, JACKSON (MS, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:SMIDT
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 W PENTAGON PL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57107-1104
Mailing Address - Country:US
Mailing Address - Phone:605-312-7800
Mailing Address - Fax:
Practice Address - Street 1:2215 W PENTAGON PL
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57107-1104
Practice Address - Country:US
Practice Address - Phone:605-312-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000173022255A2300X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer