Provider Demographics
NPI:1053059352
Name:GREEN, JEFF C
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:C
Last Name:GREEN
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 1:200 GWEE SHUT RD
Mailing Address - Street 2:
Mailing Address - City:SILETZ
Mailing Address - State:OR
Mailing Address - Zip Code:97380-2036
Mailing Address - Country:US
Mailing Address - Phone:541-444-9613
Mailing Address - Fax:
Practice Address - Street 1:200 GWEE SHUT RD
Practice Address - Street 2:
Practice Address - City:SILETZ
Practice Address - State:OR
Practice Address - Zip Code:97380-2036
Practice Address - Country:US
Practice Address - Phone:541-444-9613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8371309172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8989Medicaid