MEDICARE: MS. JAMIE LYNN SMITH ATC

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	2255A2300X	Athletic Trainer		IL

General Provider Information

NPI Number	:	1922077247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JAMIE LYNN SMITH ATC

Provider Business Mailing Address
First Line	:	94 W 24TH ST
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-4139
Country	:	US
Telephone Number	:	708-431-4732
Fax Number	:

Provider Business Practice Location Address
First Line	:	2499 E JOLIET HWY
Second Line	:
City	:	NEW LENOX
State	:	IL
Zip	:	60451-2592
Country	:	US
Telephone Number	:	815-462-9420
Fax Number	:	815-462-9421

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

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	07/08/2007

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