Provider Demographics
NPI:1154833747
Name:GREEN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 LILY TER
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-3427
Mailing Address - Country:US
Mailing Address - Phone:702-417-6511
Mailing Address - Fax:
Practice Address - Street 1:5000 DAVIS LN STE 106
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-3802
Practice Address - Country:US
Practice Address - Phone:702-417-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01794171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist