MEDICARE: JESSICA SMITH PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071.010260	IL

General Provider Information

NPI Number	:	1235639659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA SMITH PSYD

Provider Business Mailing Address
First Line	:	3426 BORGER ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75212-2723
Country	:	US
Telephone Number	:	630-715-5519
Fax Number	:

Provider Business Practice Location Address
First Line	:	4043 N RAVENSWOOD AVE STE 302
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5683
Country	:	US
Telephone Number	:	630-715-5519
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2018
Last Update Date	:	08/22/2024

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