Provider Demographics
NPI:1275508996
Name:SMITH, JACQUELINE J (MS, ATC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5117 EASTCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-5868
Mailing Address - Country:US
Mailing Address - Phone:815-267-3513
Mailing Address - Fax:
Practice Address - Street 1:3082 CATON FARM RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1455
Practice Address - Country:US
Practice Address - Phone:815-577-9936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL960017762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer