Healthcare Provider Details

I. General information

NPI: 1003218199
Provider Name (Legal Business Name): JACQUELINE PEARSON SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18640 W. BELVIDERE ROAD
GRAYSLAKE IL
60030
US

IV. Provider business mailing address

2640 NISH RD
CRYSTAL LAKE IL
60012-1509
US

V. Phone/Fax

Practice location:
  • Phone: 847-548-6000
  • Fax: 847-587-3100
Mailing address:
  • Phone: 815-557-6563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: