Provider Demographics
NPI:1164153227
Name:GREEN, JONATHAN GREGORY (FNP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GREGORY
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 1:110 AUDREY DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1500
Mailing Address - Country:US
Mailing Address - Phone:864-279-3630
Mailing Address - Fax:
Practice Address - Street 1:1701 SKYLYN DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1096
Practice Address - Country:US
Practice Address - Phone:864-393-3909
Practice Address - Fax:864-302-8433
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25841363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily