Healthcare Provider Details

I. General information

NPI: 1548675945
Provider Name (Legal Business Name): JACOB SMITH PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 03/30/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LN STE 111
BLOOMINGTON IL
61704-8112
US

IV. Provider business mailing address

611 W. PARK ST. FAPC
URBANA IL
61801
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6461
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085008559
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008559
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: