Healthcare Provider Details

I. General information

NPI: 1104077015
Provider Name (Legal Business Name): JENNIFER LYNNE SMITH PTA, ATC, NCMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 N MAIN ST STE 100
SANDWICH IL
60548-1394
US

IV. Provider business mailing address

1952 ABERDEEN CT
SYCAMORE IL
60178-3175
US

V. Phone/Fax

Practice location:
  • Phone: 815-786-6000
  • Fax: 815-786-3603
Mailing address:
  • Phone: 815-758-0000
  • Fax: 815-748-3014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160-007698
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: