Provider Demographics
NPI:1225769482
Name:GREEN, CODIE JACLYN
Entity Type:Individual
Prefix:
First Name:CODIE
Middle Name:JACLYN
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 1:17 E CHERRY
Mailing Address - Street 2:
Mailing Address - City:SUMRALL
Mailing Address - State:MS
Mailing Address - Zip Code:39482-0400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:668 OLD SALT RD
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-4232
Practice Address - Country:US
Practice Address - Phone:601-270-6968
Practice Address - Fax:601-336-5255
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS-4294235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist