Provider Demographics
NPI:1093879199
Name:GREENE, JENNIFER L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:GREENE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 220632
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-0632
Mailing Address - Country:US
Mailing Address - Phone:704-362-8480
Mailing Address - Fax:704-362-8486
Practice Address - Street 1:6220 THERMAL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5630
Practice Address - Country:US
Practice Address - Phone:704-362-8480
Practice Address - Fax:704-362-8464
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0008411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002173Medicaid