Provider Demographics
NPI:1710191564
Name:SMITH, JACK (LCPC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15040 S RAVINIA AVE STE 44
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3173
Mailing Address - Country:US
Mailing Address - Phone:708-226-1280
Mailing Address - Fax:708-226-5810
Practice Address - Street 1:15040 S RAVINIA AVE STE 44
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3173
Practice Address - Country:US
Practice Address - Phone:708-226-1280
Practice Address - Fax:708-226-5810
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional