Provider Demographics
NPI:1619558624
Name:RIVERA, JECSICA (BSN, RN)
Entity Type:Individual
Prefix:
First Name:JECSICA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4326 W MCLEAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-3548
Mailing Address - Country:US
Mailing Address - Phone:773-682-3745
Mailing Address - Fax:
Practice Address - Street 1:4326 W MCLEAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-3548
Practice Address - Country:US
Practice Address - Phone:773-682-3745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.499464163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice