Healthcare Provider Details

I. General information

NPI: 1154284057
Provider Name (Legal Business Name): JASMINE L MENDOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 S WALNUT RD
FREEPORT IL
61032-9528
US

IV. Provider business mailing address

2946 S WALNUT RD
FREEPORT IL
61032-9528
US

V. Phone/Fax

Practice location:
  • Phone: 815-235-6173
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209034154
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number209.034154
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: