Provider Demographics
NPI:1164977054
Name:GREENE, JILLIAN (PSYD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 S MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3018
Mailing Address - Country:US
Mailing Address - Phone:323-821-8194
Mailing Address - Fax:
Practice Address - Street 1:663 LILLIAN WAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-1107
Practice Address - Country:US
Practice Address - Phone:323-821-8194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30737103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical