Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 070.016666 | IL |
NPI | 1184830812 |
---|---|
Provider Name | Jeremy Smith |
First Address | Lake Forest, IL 60045-4829 |
Second Address | Lake Forest, IL 60045-4829 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/05/2007 |
Last Update Date | 18/08/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
070.016666 | IL LICENSE PT (01) | IL |
070.016666 | ILLINOIS STATE LICENSE (01) | IL |
096.002695 | IL LICENSE ATC (01) | IL |
096.002695 | ILLINOIS STATE LICENSE (01) | IL |