Provider Demographics
NPI:1114905015
Name:GREEN, CARROLL JEAN (PA C)
Entity Type:Individual
Prefix:
First Name:CARROLL
Middle Name:JEAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6518 MORNINGSAGE LN
Mailing Address - Street 2:SUITE 620
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77088-6057
Mailing Address - Country:US
Mailing Address - Phone:832-969-6744
Mailing Address - Fax:
Practice Address - Street 1:2600 S LOOP W
Practice Address - Street 2:SUITE 620
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2653
Practice Address - Country:US
Practice Address - Phone:713-661-7246
Practice Address - Fax:713-661-7248
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13366111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor