Provider Demographics
NPI:1083326854
Name:SMITH, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-9554
Mailing Address - Country:US
Mailing Address - Phone:815-409-2320
Mailing Address - Fax:
Practice Address - Street 1:EVOLVE THERAPEUTIC SERVICES CENTER
Practice Address - Street 2:304 W. MONDAMIN ST. #104
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447
Practice Address - Country:US
Practice Address - Phone:815-274-7308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
1003OtherBCBC