Provider Demographics
NPI:1003478801
Name:GREEN, JENNIFER C (MSN, APRN, NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSN, APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 E 625 S
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4300
Mailing Address - Country:US
Mailing Address - Phone:801-725-5595
Mailing Address - Fax:
Practice Address - Street 1:838 E 625 S
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4300
Practice Address - Country:US
Practice Address - Phone:801-725-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4739191-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily