Provider Demographics
NPI:1336251958
Name:CASTRO-SKOGLUND, JENECSIS
Entity Type:Individual
Prefix:
First Name:JENECSIS
Middle Name:
Last Name:CASTRO-SKOGLUND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-689-8370
Mailing Address - Fax:309-689-8380
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-689-8370
Practice Address - Fax:309-689-8380
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093944207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093944Medicaid
IL055562OtherHEALTH ALLIANCE
IL07232028OtherBLUE CROSS BLUE SHIELD
ILIL0101OtherJOHN DEERE
IL383653744OtherTAX ID
ILIL0101OtherJOHN DEERE