Provider Demographics
NPI:1174094197
Name:SMITH, JEREMY A (LSW)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 FOX DRIVE SUITE 102
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-8195
Mailing Address - Country:US
Mailing Address - Phone:217-418-1094
Mailing Address - Fax:
Practice Address - Street 1:2101 FOX DRIVE SUITE 102
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-8195
Practice Address - Country:US
Practice Address - Phone:217-766-0258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2025-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150113060104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty