Provider Demographics
NPI:1144614454
Name:CASTRO, JESSIE WAYNE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:WAYNE
Last Name:CASTRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4703 N ALBANY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1195
Mailing Address - Country:US
Mailing Address - Phone:503-956-7638
Mailing Address - Fax:
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-989-3808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125073447207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine