Provider Demographics
NPI:1114337359
Name:GREEN, JEAN
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 CREPE MYRTLE CIR
Mailing Address - Street 2:
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-3348
Mailing Address - Country:US
Mailing Address - Phone:229-325-6068
Mailing Address - Fax:
Practice Address - Street 1:232 CREPE MYRTLE CIR
Practice Address - Street 2:
Practice Address - City:OCILLA
Practice Address - State:GA
Practice Address - Zip Code:31774-3348
Practice Address - Country:US
Practice Address - Phone:229-325-6068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN174038163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical