Healthcare Provider Details

I. General information

NPI: 1235985912
Provider Name (Legal Business Name): JESSE GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 S COTTAGE GROVE AVE
CHICAGO IL
60637-2530
US

IV. Provider business mailing address

6250 S COTTAGE GROVE AVE
CHICAGO IL
60637-2530
US

V. Phone/Fax

Practice location:
  • Phone: 773-663-9639
  • Fax:
Mailing address:
  • Phone: 312-682-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.010877
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: