Provider Demographics
NPI:1033658828
Name:GREEN, JAMIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 N 23RD ST APT 2408
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1577
Mailing Address - Country:US
Mailing Address - Phone:781-820-1362
Mailing Address - Fax:
Practice Address - Street 1:700 E TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-5733
Practice Address - Country:US
Practice Address - Phone:888-985-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP025925363LF0000X
PASP017214363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics