Provider Demographics
NPI:1124403100
Name:SMITH, JONATHAN (PSYD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5412 N CLARK ST STE 220
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1272
Mailing Address - Country:US
Mailing Address - Phone:773-985-8746
Mailing Address - Fax:773-880-1321
Practice Address - Street 1:5412 N CLARK ST STE 220
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1272
Practice Address - Country:US
Practice Address - Phone:773-985-8746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.010187101YM0800X
IL071.009490103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health