Healthcare Provider Details

I. General information

NPI: 1982830238
Provider Name (Legal Business Name): JACINTA GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9401 HOLY CROSS LN
BREESE IL
62230-3510
US

IV. Provider business mailing address

825 WOODLEA RD
KANKAKEE IL
60901-8199
US

V. Phone/Fax

Practice location:
  • Phone: 618-526-7271
  • Fax:
Mailing address:
  • Phone: 815-937-0552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036.139092
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.139092
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125:056090
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: