Provider Demographics
NPI:1326339938
Name:GREEN, JENNIFER SUSAN (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:SUSAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:SUSAN
Other - Last Name:PROG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN, MSN
Mailing Address - Street 1:28535 LAKE PARK DR W
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-4621
Mailing Address - Country:US
Mailing Address - Phone:248-225-2826
Mailing Address - Fax:
Practice Address - Street 1:28535 LAKE PARK DR W
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-4621
Practice Address - Country:US
Practice Address - Phone:248-225-2826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704144751163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse