Provider Demographics
NPI:1003100868
Name:GREENE, JARED
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:GREENE
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 1:545 N 500 W
Mailing Address - Street 2:
Mailing Address - City:MANTI
Mailing Address - State:UT
Mailing Address - Zip Code:84642-1041
Mailing Address - Country:US
Mailing Address - Phone:435-851-9126
Mailing Address - Fax:
Practice Address - Street 1:50 S MAIN ST STE 21
Practice Address - Street 2:
Practice Address - City:MANTI
Practice Address - State:UT
Practice Address - Zip Code:84642-1378
Practice Address - Country:US
Practice Address - Phone:435-851-9126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1Medicaid