Provider Demographics
NPI:1124002035
Name:GREENE, JACQUELIN LONDON (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELIN
Middle Name:LONDON
Last Name:GREENE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:276-883-8086
Mailing Address - Fax:276-883-8090
Practice Address - Street 1:58 CARROLL ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-883-8086
Practice Address - Fax:276-883-8090
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168638363LF0000X
TN14888363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1124002035Medicaid
VA0024168638OtherVIRGINIA LICENSE
TNQ003735Medicaid
VA0024168638OtherVIRGINIA LICENSE
VAC09112Medicare UPIN