Provider Demographics
NPI:1356659221
Name:GREEN, JENNIFER (LPN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-2269
Mailing Address - Country:US
Mailing Address - Phone:402-981-8640
Mailing Address - Fax:
Practice Address - Street 1:2231 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3907
Practice Address - Country:US
Practice Address - Phone:402-291-1203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP54382164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse