Healthcare Provider Details

I. General information

NPI: 1609349026
Provider Name (Legal Business Name): JESSICA SMITH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 JONATHAN CREEK RD
ARTHUR IL
61911-6108
US

IV. Provider business mailing address

808 S DON RYAN ST
HAMMOND IL
61929-7219
US

V. Phone/Fax

Practice location:
  • Phone: 217-962-0614
  • Fax:
Mailing address:
  • Phone: 217-259-5450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.020428
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: