Provider Demographics
NPI:1144622382
Name:GREEN, JONATHAN (FNP)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 BERKSHIRE PL
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07401-2005
Mailing Address - Country:US
Mailing Address - Phone:518-729-6155
Mailing Address - Fax:
Practice Address - Street 1:51 BERKSHIRE PL
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:NJ
Practice Address - Zip Code:07401-2005
Practice Address - Country:US
Practice Address - Phone:518-729-6155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY624738163W00000X
NY339165363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse