Provider Demographics
NPI:1972932184
Name:SMITH, JENNIFER JO (MS, PT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JO
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:JO
Other - Last Name:HARSHBARGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PT
Mailing Address - Street 1:411 UVEDALE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2067
Mailing Address - Country:US
Mailing Address - Phone:708-442-6193
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5823
Practice Address - Country:US
Practice Address - Phone:847-904-5057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.010925225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist