Provider Demographics
NPI:1821828013
Name:SMITH, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
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 1:2499 FOX DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-6412
Mailing Address - Country:US
Mailing Address - Phone:630-715-0144
Mailing Address - Fax:
Practice Address - Street 1:3381 W MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1008
Practice Address - Country:US
Practice Address - Phone:630-649-0511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-03
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist