Provider Demographics
NPI:1235696774
Name:GREENE, JESSICA YVONNE (LPC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:YVONNE
Last Name:GREENE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 CHESTNUT RD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-5502
Mailing Address - Country:US
Mailing Address - Phone:843-945-1452
Mailing Address - Fax:843-945-1489
Practice Address - Street 1:630 CHESTNUT RD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-5502
Practice Address - Country:US
Practice Address - Phone:843-945-1452
Practice Address - Fax:843-945-1489
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6590101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health