Provider Demographics
NPI:1235275462
Name:GREEN, JEFFREY J (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:GREEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ROYAL PARK DR
Mailing Address - Street 2:STE 2
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-2242
Mailing Address - Country:US
Mailing Address - Phone:616-772-1370
Mailing Address - Fax:616-772-9774
Practice Address - Street 1:1 ROYAL PARK DR
Practice Address - Street 2:STE 2
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-2242
Practice Address - Country:US
Practice Address - Phone:616-772-1370
Practice Address - Fax:616-772-9774
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501000893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G01087OtherBLUE CROSS BLUE SHIELD MI
MI0G01087OtherBLUE CROSS BLUE SHIELD MI