Healthcare Provider Details

I. General information

NPI: 1578530903
Provider Name (Legal Business Name): JENNIFER N SMITH ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N INDEPENDENCE BLVD
ROMEOVILLE IL
60446-1898
US

IV. Provider business mailing address

16129 W PENNYROYAL LN
LOCKPORT IL
60441-4135
US

V. Phone/Fax

Practice location:
  • Phone: 847-692-8356
  • Fax:
Mailing address:
  • Phone: 815-530-2127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number96000794
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: