Healthcare Provider Details

I. General information

NPI: 1952226532
Provider Name (Legal Business Name): JACKIE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2N564 BERNICE AVE
GLEN ELLYN IL
60137-2823
US

IV. Provider business mailing address

2N564 BERNICE AVE
GLEN ELLYN IL
60137-2823
US

V. Phone/Fax

Practice location:
  • Phone: 815-514-4789
  • Fax:
Mailing address:
  • Phone: 815-514-4789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number217.010815
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: