Provider Demographics
NPI:1497931497
Name:SMIDDY, JENNIFER (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SMIDDY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KOONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:4020 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-5010
Practice Address - Country:US
Practice Address - Phone:765-641-7605
Practice Address - Fax:765-641-7607
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10970225100000X
IN05012098A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48351750Medicaid
COCOAAA3856Medicare PIN