Individual
MR. JACOB SMITH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C, ATC
Contact information
Practice address
1111 TRINITY LN STE 111, BLOOMINGTON, IL 61704-8112
(309) 663-6461
Mailing address
611 W. PARK ST., FAPC, URBANA, IL 61801
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085008559
IL
363AM0700X
Medical Physician Assistant
085008559
IL
Other
Enumeration date
06/24/2014
Last updated
03/30/2022
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