Provider Demographics
NPI:1982830238
Name:GREEN, JACINTA (MD)
Entity Type:Individual
Prefix:DR
First Name:JACINTA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 WOODLEA RD
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-8199
Mailing Address - Country:US
Mailing Address - Phone:815-937-0552
Mailing Address - Fax:
Practice Address - Street 1:4425 W 63RD ST STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5565
Practice Address - Country:US
Practice Address - Phone:888-876-7012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125:056090207R00000X
IL036.139092207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036139092Medicaid