Basic Information
| Provider Information | |||||||||
| NPI: | 1104588979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1323 S 49TH CT | ||||||||
| Address2: | |||||||||
| City: | CICERO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608041406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8722031703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2233 W DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606228151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127702000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2021 | ||||||||
| LastUpdateDate: | 10/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209022090 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.