Provider Demographics
NPI:1104077015
Name:SMITH, JENNIFER LYNNE (PTA, ATC, NCMT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA, ATC, NCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 ABERDEEN CT
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3175
Mailing Address - Country:US
Mailing Address - Phone:815-758-0000
Mailing Address - Fax:815-748-3014
Practice Address - Street 1:1310 N MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1394
Practice Address - Country:US
Practice Address - Phone:815-786-6000
Practice Address - Fax:815-786-3603
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
IL160-007698225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner