Provider Demographics
NPI:1104306828
Name:SMITH, JOBRIL MARQUEZ
Entity type:Individual
Prefix:
First Name:JOBRIL
Middle Name:MARQUEZ
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 N THOMPSON DR APT 1
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-1737
Mailing Address - Country:US
Mailing Address - Phone:901-600-8409
Mailing Address - Fax:
Practice Address - Street 1:1955 W BROADWAY
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53713-3700
Practice Address - Country:US
Practice Address - Phone:608-285-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator