Provider Demographics
NPI:1760838965
Name:SMITH, JACOB MATTHEW
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MATTHEW
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 N MOZART ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3644
Mailing Address - Country:US
Mailing Address - Phone:773-292-8300
Mailing Address - Fax:773-292-2601
Practice Address - Street 1:1044 N MOZART ST STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3644
Practice Address - Country:US
Practice Address - Phone:773-292-8300
Practice Address - Fax:773-292-2601
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036149766207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program