Provider Demographics
NPI:1134866387
Name:SMITH, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 N ELSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-1544
Mailing Address - Country:US
Mailing Address - Phone:309-714-8330
Mailing Address - Fax:
Practice Address - Street 1:1739 N ELSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1544
Practice Address - Country:US
Practice Address - Phone:773-687-9241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-22-216144106S00000X
ILBACB786156103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician