Provider Demographics
NPI:1124363684
Name:GREEN, JENNIFER A (EDS)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5431 CLAIRMONT LN
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-7810
Mailing Address - Country:US
Mailing Address - Phone:843-821-3973
Mailing Address - Fax:
Practice Address - Street 1:5431 CLAIRMONT LN
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7810
Practice Address - Country:US
Practice Address - Phone:843-821-3973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC102627103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist