MEDICARE: JASMINE L MENDOZA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	209.034154	IL

General Provider Information

NPI Number	:	1154284057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE L MENDOZA

Provider Business Mailing Address
First Line	:	2216 LAMAR ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-8071
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2216 LAMAR ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-8071
Country	:	US
Telephone Number	:	815-980-7335
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2025
Last Update Date	:	12/08/2025

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Directions to “ JASMINE L MENDOZA ” Practice Location

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