Provider Demographics
NPI:1033507363
Name:GREENE, JENNIFER (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NEWPORT CENTER DR
Mailing Address - Street 2:#213
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7501
Mailing Address - Country:US
Mailing Address - Phone:949-644-1322
Mailing Address - Fax:949-644-0316
Practice Address - Street 1:505 N EUCLID ST
Practice Address - Street 2:STE 680
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-5506
Practice Address - Country:US
Practice Address - Phone:714-780-0010
Practice Address - Fax:714-780-0050
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 41967225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB228642OtherMEDICARE PTAN