1972932184 NPI number — MRS. JENNIFER JO SMITH M.S., P.T.

Table of content: MRS. JENNIFER JO SMITH M.S., P.T. (NPI 1972932184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972932184 NPI number — MRS. JENNIFER JO SMITH M.S., P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JENNIFER
Provider Middle Name:
JO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARSHBARGER
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S., P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972932184
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 UVEDALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60546-2067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-442-6193
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3703 W LAKE AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GLENVIEW
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60026-5823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-904-5057
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  070.010925 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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