Healthcare Provider Details

I. General information

NPI: 1457578197
Provider Name (Legal Business Name): JENNIFER SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/23/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 S DEER RD
MACOMB IL
61455-2602
US

IV. Provider business mailing address

460 S DEERE RD
MACOMB IL
61455
US

V. Phone/Fax

Practice location:
  • Phone: 309-575-3960
  • Fax: 309-575-3988
Mailing address:
  • Phone: 309-333-9829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: