Individual
JEREMY SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1920 FOOTBALL DR, LAKE FOREST, IL 60045-4829
(847) 739-5405
Mailing address
1920 FOOTBALL DR, LAKE FOREST, IL 60045-4829
(847) 739-5405
Taxonomy
Speciality
Code
Description
License number
State
2251S0007X
Sports Physical Therapist
Primary
070.016666
IL
2255A2300X
Athletic Trainer
096.002695
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
070.016666
ILLINOIS STATE LICENSE
IL
01
—
096.002695
ILLINOIS STATE LICENSE
IL
Enumeration date
05/16/2007
Last updated
08/18/2013
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