Provider Demographics
NPI:1073951455
Name:GREENE, JACLYN M (MA, LMHP-E)
Entity Type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:M
Last Name:GREENE
Suffix:
Gender:F
Credentials:MA, LMHP-E
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 WESTOVER HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4434
Mailing Address - Country:US
Mailing Address - Phone:804-922-3894
Mailing Address - Fax:
Practice Address - Street 1:1210 WESTOVER HILLS BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4434
Practice Address - Country:US
Practice Address - Phone:804-922-3894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1790932911Medicaid