Provider Demographics
NPI:1174094197
Name:SMITH, JEREMY ALEXANDER
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:ALEXANDER
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 1:1422 ROSE DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-4949
Mailing Address - Country:US
Mailing Address - Phone:217-418-1094
Mailing Address - Fax:
Practice Address - Street 1:102 E MAIN ST STE 403
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2744
Practice Address - Country:US
Practice Address - Phone:217-531-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty