Provider Demographics
NPI:1093861932
Name:GREEN, JACQUALYN F (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUALYN
Middle Name:F
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 KINGSWAY DR STE 308
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1571
Mailing Address - Country:US
Mailing Address - Phone:317-257-6773
Mailing Address - Fax:317-863-1414
Practice Address - Street 1:4755 KINGSWAY DR STE 308
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1571
Practice Address - Country:US
Practice Address - Phone:317-257-6773
Practice Address - Fax:317-863-1414
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000712A1041C0700X
IN35000324A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist