Provider Demographics
NPI:1164818233
Name:GREEN, JASON KYLE (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:KYLE
Last Name:GREEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 EXETER RD STE 250
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3931
Practice Address - Country:US
Practice Address - Phone:901-767-5864
Practice Address - Fax:901-767-6591
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS30295207RC0200X, 207RP1001X, 207RS0012X
TN4746207RC0200X, 207RS0012X, 207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program