Provider Demographics
NPI:1346628484
Name:GREENE, JESSICA NICHOLE (DO)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICHOLE
Last Name:GREENE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:NICHOLE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:233 SGT ED HOLCOMB BLVD S
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-1990
Mailing Address - Country:US
Mailing Address - Phone:936-756-8331
Mailing Address - Fax:
Practice Address - Street 1:405 W GRAND AVE
Practice Address - Street 2:MEDICAL EDUCATION DEPARTMENT
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4720
Practice Address - Country:US
Practice Address - Phone:937-723-3245
Practice Address - Fax:937-723-5017
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS11102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry