Healthcare Provider Details

I. General information

NPI: 1104588979
Provider Name (Legal Business Name): JESSICA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2021
Last Update Date: 05/06/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

779 W ADAMS ST
CHICAGO IL
60661-3509
US

IV. Provider business mailing address

1323 S 49TH CT
CICERO IL
60804-1406
US

V. Phone/Fax

Practice location:
  • Phone: 312-382-8308
  • Fax:
Mailing address:
  • Phone: 872-203-1703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209022090
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: