Provider Demographics
NPI:1033097639
Name:SMITH, JACK OSCAR REED (PT, DPT)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:OSCAR REED
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-1446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1567 DEERFIELD PKWY
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-2653
Practice Address - Country:US
Practice Address - Phone:847-520-9038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist