Provider Demographics
NPI:1609349026
Name:SMITH, JESSICA (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 S DON RYAN ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IL
Mailing Address - Zip Code:61929-7219
Mailing Address - Country:US
Mailing Address - Phone:217-259-5450
Mailing Address - Fax:
Practice Address - Street 1:2046 JONATHAN CREEK RD
Practice Address - Street 2:
Practice Address - City:ARTHUR
Practice Address - State:IL
Practice Address - Zip Code:61911-6108
Practice Address - Country:US
Practice Address - Phone:217-962-0614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.020428225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty