Provider Demographics
NPI:1144787250
Name:GREEN, JARRED MATTHEW
Entity Type:Individual
Prefix:
First Name:JARRED
Middle Name:MATTHEW
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2836
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82602-2836
Mailing Address - Country:US
Mailing Address - Phone:307-577-0722
Mailing Address - Fax:307-577-4256
Practice Address - Street 1:123 W 1ST ST # 700B
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2481
Practice Address - Country:US
Practice Address - Phone:307-577-0722
Practice Address - Fax:307-577-4256
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty