Provider Demographics
NPI:1073064242
Name:GREEN, JENNIFER NICOLE (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W 190TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2421 COUNTY ROAD 16
Practice Address - Street 2:
Practice Address - City:LOUIN
Practice Address - State:MS
Practice Address - Zip Code:39338-3230
Practice Address - Country:US
Practice Address - Phone:931-384-8212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22027363LF0000X
MS903916363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily